Physical Exam of the Lower Spine

Courtesy: Prof Nabil Ebraheim, University of Toledo, Ohio, USA

Sequence of Examination

1. Gait

2. Inspection

3. Palpation

4. Movements

5. Measurements

6. Special tests

7. Neurological examination

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1. Gait Assessment

Observe the patient walking normally and while turning.

• Shuffling gait

• Slap foot gait

• Broad-based or halting gait

• Antalgic gait

• Trendelenburg gait

• High-stepping gait

• Hemiplegic or circumduction gait

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2. Inspection

Inspection should be performed from the front, side, and back with the patient standing upright and adequately exposed.

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Inspection from the Front

• Normally, the head and neck are aligned with the chest and lower spine.

• In torticollis:

  • The neck is tilted to one side.

  • The chin is rotated to the opposite side.

• Facial tilt may be seen in acquired torticollis due to:

  • Tonsillar infection

  • Vertebral body infection

  • Klippel–Feil syndrome

• Compare both sternocleidomastoid muscles for:

  • Symmetry

  • Swelling (sternomastoid tumor)

  • Tightness or unilateral shortening, suggestive of congenital muscular torticollis

• Observe the supraclavicular fossae:

  • Normally hollow

  • Fullness may indicate abscess, Pancoast tumor, or rarely a complete bony cervical rib

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Inspection from the Side

• Ask the patient to stand erect.

• Assess normal spinal curvatures:

  • Cervical lordosis

  • Thoracic kyphosis

  • Lumbar lordosis

Abnormal Findings

• Loss of cervical lordosis:

  • Seen in ankylosing spondylitis

• Knuckle deformity:

  • Collapse of a single vertebra

• Angular deformity:

  • Collapse of 2 to 3 vertebrae

• Round back deformity:

  • Collapse of 4 or more vertebrae

• Exaggerated lumbar lordosis (hyperlordosis), usually compensatory:

  • Developmental dysplasia of the hip

  • Flexion deformity of the hip

  • Spondylolisthesis

• Loss of lumbar lordosis:

  • Ankylosing spondylitis

  • Intervertebral disc prolapse due to muscle spasm

  • Spinal infections

  • Vertebral compression fracture

  • Degenerative disc disease

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Inspection from the Back

• Both shoulders and iliac crests should be at the same level.

• Head, neck, spine, and natal cleft should lie in a straight vertical line.

• Look for:

  • Scoliosis

  • Step-off deformity

  • Surgical scars

  • Sinuses

  • Swelling

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3. Palpation

Palpate gently and systematically.

1. Local rise of temperature

2. Spinal tenderness

3. Alignment of spinous processes

4. Step-off between adjacent spinous processes

5. Paraspinal muscle spasm

6. Any swelling or scars

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4. Movements

Assess active and passive movements and note pain, restriction, or spasm.

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Cervical Spine Movements

• Flexion (sagittal plane): 0 to 80 degrees

• Extension (sagittal plane): 0 to 50 degrees

• Lateral bending (coronal plane): 0 to 45 degrees

• Rotation (axial plane): 0 to 80 degrees

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Lumbar Spine Movements

• Flexion

• Extension

• Lateral bending

• Rotation

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5. Measurements

• Chest expansion

• Modified Schober test

• Wall–occiput distance

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6. Special Tests

Lumbar Spine and Nerve Root Tests

• Straight leg raising test (Lasegue test)

• Bragard test

• Bowstring sign

• Femoral nerve stretch test

Cervical Spine Tests

• Lhermitte maneuver

• Axial compression test

• Spurling test

• Cervical distraction test

Other Tests

• Beevor sign

• Figure-of-four test

• Adson test

• Roos test

• Romberg test

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7. Neurological Examination

• Motor examination of upper and lower limbs

• Sensory examination

• Deep tendon reflexes

• Pathological reflexes when indicated

• Rectal examination when required to assess:

  • Sacral nerve function

  • Cauda equina involvement

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Summary

• Spine examination must be systematic and sequential.

• Inspection and gait often provide early diagnostic clues.

• Movements, measurements, and special tests help localize pathology.

• A complete neurological examination is essential in all patients with spinal complaints.