Detailed history and its evaluation , examination of spine in general and local with special tests in cervical , thoracic outlet syndrome , lumbar spine and SI joint with diagrams, neurological examination both sensory and motor.

1. EXAMINATION OF SPINE
Dr.Prasanth

3. HISTORY

5. • PAIN : most common symptom reported in spine disorders
1.Onset of pain – Acute(IVDP , Discitis or traumatic
conditions )
- Insidious( Infection like TB , Degenerative or
inflammatory conditions like AS ).
2.Timing of pain – Night time ( Infection, inflam. , malignancy)
- Mechanical pain comes with activity
(Degenerative , Osteoporosis ).
3.Site of pain - cervical region ,dorsal region, lumbodorsal
region or lumbar region , lumbosacral region or sacral
region.

6. 4.Nature of pain-
- Stabbing –PIVD
- Continous and throbbing type in osteomyelitis
- Intermittent pain –spondylolisthesis
- Dull ache in pott’s disease .
5.Radiation – Backache or neck pain with radiation towards
limbs is suggestive of nerve root involvement.
Nerve roots effecting C5,6,7 causing radicular pain over the
radial aspect of arm , forearm and hand

7. • Nerve roots effecting L4,5, S1 causing radicular pain over
the back of thigh , leg and the foot.
6.Aggravating factors –
Increase in pain while bending
forward, coughing, sneezing or turning
in bed in typical in acute IVDP of LS.
pain on bending forward/ Heavy wt. lifting : IVDP of LS spine.
pain on bending backward : Lumbar canal stenosis ,
spondylolysis , spondylolisthesis and facet arthropathy.

9. 7.Relieving factors –
pain relieved at rest : Degenerative conditions like
spondylosis , listhesis ,canal stenosis and osteoporosis.
pain felt during rest : Inflammatory / Infective /
Tumour pathologies.
8.Associated stiffness in mrg and at rest -
In AS and spondyloarthropathies.
9.Walking distance –
in lumbar canal stenosis, walking distance may
decrease due to neurogenic claudication.

11. • DEFORMITY - localized/diffuse ,onset , Duration and
progression
• SWELLING – congenital(spina bifida), Acquired(cold
abscess)
• RESTRICTION OF MOTION
• NEUROLOGICAL SYMPTOMS – motor weakness and sensory
symptoms , Bowl and bladder involvement.
• DIZZINESS – In cervical spondylosis due to osteophytes
encroaching the vertebral artery foramen leading to
vertebro basilar insufficiency.

12. Examination of spine
• General examination

13. Local examination
• Gait : If person is ambulant , gait is assessed before
examining the spine. If there is impending neurological
deficit there, then assessment of gait should be absolutely
avoided.
• Attitude : can be commented in any position.
• Inspection : involves inspection from front , side and back.
1. ALIGNMENT –
From front: normally head and neck are central, in
torticollis , the neck is tilted to one side
shape and abdominal protuberance must be looked for.

14. From side: Look from the side
Normal spine- cervical lordosis, thoracic kyphosis,
lumbar lordosis.
Exaggerated lordosis is mostly compensatory seen in DDH,
flexion deformity of hip and spondylolisthesis.
Loss of cervical lordosis seen in AS.
Loss of lumbar lordosis seen in AS , IVDP , Spinal infections, or
flatback syndrome.

17. From behind: normally head, neck, spine and natal cleft
are in one line ( PLUMB Line – from occiput to natal cleft )
Scoliosis is best noted from behind
It must be examined from behind in standing & sitting posture
 Functional scoliosis – present in standing and disappear on
sitting , often due to limb length discrepancy or acute para
spinal muscle spasm.

18. Structural scoliosis – persists on standing, sitting or
lying down.
 Mobile structural scoliosis: scoliosis disappears on
bending forward.
 Rigid structural scoliosis: deformity does not
disappear.
This is ADAM’S TEST

19. Any list : Acute spasm of the spinal muscles due to
pain leads to abrupt lateral shift of the trunk above
a certain point.
It is also known as Trunk list/ Lateral shift/ Acute
lumbar sciatic scoliosis/ Wind swept spine.
It’s either ipsi/contralateral to the side of the pain.
This spasm avoids irritation of nerve roots.

20. List: Axillary disc-same
side
shoulder disc-opp. side

21. 2. The level of shoulder and pelvis –
Normal both shoulder and pelvis are at the same level.
Tilt of the pelvis , if any , should be noted.
3. Neck and Scapula -
note hair line: low hairline is seen in klippel feil syndrome ,
Turner syndrome.
webbing of neck: short webbed neck in
klippel feil synd.
Any high riding scapula (sprengel shoulder).

22. 4. Skin of the back and elsewhere –
presence of café-au-lait spots(Ass. With scoliosis)
, tuft of hair ,dimple or hemangioma(Ass. With spina bifida
occulta) should be looked.

23. 5. Swelling – look for cold abscess , right hump( ass. With
rigid structural scoliosis of the thoracic spine).
spina bifida aperta- swelling on midline over the lumbar
spine.muscle spasm and a
6.The attitude and deformity of upper and lower limb and
check for muscle spasm and atrophy.

24. Palpation
1. Local rise of temperature
2. Spine tenderness
3. Paraspinal spasm
4. Normal bony landmarks
5. Other soft tissues
6. Deformity of the back, upper and lower limb

26. Movements of various regions of spine:
Cervical, Dorsal and Lumbar
 CERVICAL SPINE
 Forward flexion
 Normal : 0 to 50 degrees
 Extension
 Normal : 0 to 60 degrees
 Lateral flexion
 Normal : 0 to 45 degrees
 Lateral Rotation
 Normal : 0 to 80 degrees

27. Dorsal spine
 Rotation to left and right
 Normal : 45 degrees
 lumbar spine
 Forward flexion (Schober’s test)
 Normal : 0 to 60 degrees
 Extension
 Normal : 0 to 25 degrees
 Lateral flexion
 Normal : 0 to 30 degrees

28. (a) Assessment of lumbar spine flexion : Bending
forward , Modified schober’s method.
• Bending forward method
-ability to touch the ground / how
many cm away from the ground

29. It decreases in Ankylosing spondylitis

30. (b) Extension
But in AS, there is loss of extension of spine , so occiput fails
to touch the wall

31. (c) Lateral flexion
Angle between the imaginary vertical midline axis and the
straight line joining T1 and S1 vertebra is measured.

32. Measurement
1. The linear measurement – of spine has less value
in clinical diagnostics.
2. Chest expansion – normal expansion is about 5cm.
it is decreased in AS.
3. Limb length discrepancy – if relevant for the case

33. Special tests for Cervical spine

34. Cervical distraction test
• Procedure: The patient is seated. The
examiner grasps the patient's head
about the jaw and the back of the head
and applies superior axial traction.
• Assessment: Distraction of the cervical
spine reduces the load on the
intervertebral disks and exiting nerve
roots within the affected levels or
segments while producing a gliding
motion in the facet joints.
• Test is positive if neuro symptoms or
pain reduced with traction force

46. Adson's (Scalene) Test

49. Wright's hyperabduction test
•Arm hyperabducted to 180°-
diminishing radial pulse.
•Neurovascular structures
compressed in subcoracoid region
by pectoralis minor tendon, head of
humerus or coracoid process.

50. Roos test(EAST)-elevated arm stress
test
• Hold both arms in surrendering position (90°overhead
with shoulders in external rotation) – reproduction of
symptoms within 1 minute . Arm collapses if continued.
modified Roos test / Elevated Arm Stress
Test(EAST)– same as above. Symptoms
precipitated by opening and closing fists
continuously.

51. Special tests for lumbar spine
1. Straight leg raising test ( SLRT )
- performed to confirm the lumbar nerve root
( L4 onwards ) irritation / compression.
• If the pain is evoked under 60 degrees it suggests
impingement of the protruding intervertebral disc on a
nerve root.
• If the pain is evoked at an angle above 60 degree
It indicates tension on nerve root that is abnormally
sensitive from a cause not necessarily an
intervertebral disc protrusion

54. 3. Lasegue test

55. Recurrence of pain with dorsiflexion
of ankle confirms the root irritation.

56. 4.Well leg raising test / Crossed SLRT /contralateral
SLRT/ Fajersztajn test

58. Pathognomonic for
axillary type of lumbar IVDP

61. 7.Femoral nerve stretch test / Reverse
SLRT

62. Special tests for Sacroiliac joint
1. Figure of 4 test / FABER test / Patricks test

66. Pelvis distraction test

69. Goldthwait’s test
• Test can be used to differentiate between lumbar spine
and sacroiliac joint pathology.
• Patient supine, examiner slowly raises the patient’s affected
leg with one hand while palpation motion at the lumbar
spine with the other hand.
• Test is then repeated on the opposite side.
• There are two interpretation for a positive Goldthwait’s
test.
• Pain before lumbar spine motion is felt: Sacroiliac joint
pathology (ligamentous sprain, arthritis).
• Pain beginning when lumbar spine motion is felt:
Lumbosacral pathology (sprain/strain, possible disc

70. Goldthwait’s test

71. Sacral thrust test

72. Cluster of laslett for SI joint
• Uses 4 provocative tests , atleast 2 tests must be (+)
• Sensitivity : 88% , Specificity : 78%

73. Algorithm for laslett test

74. Cluster of Van der Wurff
• Uses 5 SI joint provocation tests , at least 3 must be
positive.
• Sensitivity : 85% , Specificity : 79%
• 5 tests – Pelvic distraction test
- Thigh thrust test
- Pelvic compression test
- Gaenslen test
- Patricks / FABER / Figure of 4 Test

75. Neurological examination
• Higher mental function
• Cranial nerves
• Motor function
• Sensory function
• Reflexes
• Visceral functions
• Involuntary movements
• Gait

76. •Motor system
a. Bulk of muscle ( wasting or hypertrophy)
b. Tone of muscle
i. Hypertonia
1. Spasticity
2. Rigidity
ii. hypotonia – flaccidity
c. Power of muscle
d. Reflexes

77. Myotomes
• C5 – Elbow flexion
• C6 – Wrist extension
• C7 – Elbow extension
• C8 – Finger flexion
• T1 – Finger abduction
L2 Hip flexion
L3 Knee extension
L4 Dorsiflexion
L5 Great toe
extension
S1 Plantarflexion

78. Dermatomes
• Upper limb
• C5 -
• C6 -
• -
• C7 -
• C8 -
• -
• T1 -
• -
• T2 -
lateral forearm
lateral forearm
thumb and index finger
middle finger
ring and little fingers
medial forearm medial
elbow
distal half of the medial arm
proximal half of medial arm

81. Thank you