Spine Exam

October 18, 2005

James Shaffer
Proctor Dr. Gorek
 Overview
 History
 Basic Exam
 Special tests
 Sacroiliac Disease
 Non-organic signs
 History
 Assess
– Symptoms
– Basic description
 Location
 Quality
 Onset
 Severity
 Exacerbation/palliation
 Associated sx’s
– Disability
– Symptoms with ADL’s or only with strenuous activity
 History
 Other symptoms
– Urinary retention
 Often frequency or urgency (overflow) in milder
cases
– Fecal incontinence
– Coordination issues
– Clumsiness
 Referred pain
 From disc, facet joints (discogenic pain
somewhat controversial)
 May be felt in buttocks and proximal
thighs (lumbar) or shoulder girdle
(cervical)
 No distal radiation
 Cauda Equina
 Urinary retention
 Saddle anesthesia
 Back pain
 Sometimes sacral muscle weakness
Neurogenic vs. Vascular Claudication
 Basic Exam
 Gait
 Posture
 Range of Motion
 Palpation
– Tenderness
 Neuro Exam
 Special Tests
 Neck Musculature
 Flexion
– Primary
 Sternocleidomastoids (CN XI)
– Secondary
 Scalenus Mm. , Prevertebral Mm.
 Extension
– Paravertebral Ext (splenius semispinalis,
capitis [post cervical roots])
– Trapezius
 Neck Muscles Cont.
 Lateral Rotation
– Sternocleidomastoid
 Lateral Bending
– Scalenus Mm. (branches of various lower
cervical roots)
 Cervical Range of Motion
 Flexion
– Chin to chest
 Extension
– Occiput to back
 Lateral Rotation
– 90 degrees
 Lateral Bending
– 45 degrees
 Symptoms with movement
 Lumbar Motion
 Flexion
– Increased pressure on disc
– Increased space in foramina and canal
– Measure distance from fingertips to floor
– Measure skin stretch posteriorly (Schober’s
test)
 Extension
– Worsens pain from stenosis, spondylolisthesis
 Lateral bending and Rotation
– Compare sides
 Palpation-cervical
 Spinous processes (C7-T1 esp)
 Transverse processes
 Occiput
 Supraclavicular fossa (cervical rib or nodes)
 Hyoid C3
 Thyroid cart. C4-5
 Cricoid C6
 Carotid Tubercle C6 (palpate unilaterally)
 Muscle spasm
 Neuro Exam
 Strength
 Sensation (inc two-point and vibratory)
 DTR’s
 Coordination (Tandem gait, Rapid alt
movement, fine motor, etc)
 Upper motor neuron signs
 Rectal
 Other reflexes and provocative tests
 Neuro Levels
 C2
– Sensation-scalp, upper part of ant neck
 C3
– pain radiating to back of neck, mastoid and
ear;
– Sensation-neck
 C4
– Pain-back of neck, superior scapula, chest
wall;
– Sensation-superior portion of shoulder girdle
 Motor-mainly
deltoid
 May have pain in
shoulder and
lateral arm
 Biceps reflex also
some C6
 Sensation best
over lateral
deltoid
 Biceps-C5/6
 Wrist Ext- C6/7
 FCR-C7
 FCU-C8
 Sensation
may overlap
 Thoracic
 Sensory
– T4-nipple line
– T7-xiphoid
– T10-umbilicus
– T12-inguinal crease
 Motor
– Partial sit-up
– T5-T10 innervates upper abdominals
– T10-L1 lower
– Beevor’s sign
Thoracic Motor
 L1-L3
 Motor
– Iliopsoas- mainly L1/2, some L3
– Quadriceps- mainly L3/4, some L2
– Hip adductors- L2/3/4
 Sensation
– L1, oblique band below inguinal ligament
– L3, oblique band above patella
 Heel walk for Tib
Ant
 Quad reflex L2-4
 Gluteus Medius also
L5 (trendelenburg
test)
 Posterior Tibialis-L5
DTR
 1st Dorsal web for
sensory
 Motor also
– Gastroc-soleus: use
toe walk
– Glut Max: resist hip
ext with bent knee
 S2-4
 Motor
– External Anal Sphincter
– Bladder
– Intrinsic foot musculature
 Sensation
– S2 posterior thigh
– S3 saddle area
– S4/5 perianal
 Reflexes
– Superficial anal
– Bulbocavernosus
 Neuro vs. Bony Levels
 Cervical nerves exit above corresponding
vertebrae
 TLS nerves exit below vertebrae
 Cervical Disc usually affects nerve at same
level (C6/7 disc gets C7)
 Lumbar Disc
– Posterolateral affects next lower (L4/5 disc-L5
root)
– Far Lateral affects exiting root (L4/5 disc-L4
root)
 Upper Motor Neuron Signs
 These are indicative of myelopathy (or
cerebral damage)
 Include
– Increased DTR’s, spasticity
– Clonus
– Pathologic reflexes
– Absence of superficial reflexes
– Decreased coordination, speed
 Hoffman’s
 Firmly flick middle fingertip
 Positive if flexion at thumb IP and index DIP
 Inverted Radial Reflex
 Brachioradialis reflex results in flexion of thumb
and fingers
 Finger Escape Sign
 Pt asked to hold fingers adducted and extended
 30 seconds
 Positive if ulnar two tend to flex and abduct
 Superficial Abdominal Reflex
 Gently stroke each
quadrant
 Normal response is
umbilicus moving
toward stimulus
 Absence indicates
upper motor
neuron deficit
 Cremasteric Reflex
 Absent unilaterally-
lower motor lesion
L1/L2
 Absent bilaterally-
upper motor lesion
 Superficial Anal Reflex
 Anal wink in response to gentle stroking of
perianal skin
 Mediated by S2/3/4
 Lower Extremity Upper Motor
Neuron Signs
 Babinski
 Oppenheim Test-
– Fingernail or hammer
along crest of tibia
– Normal is no reaction
– Abnormal is same as
babinski
 Special Tests
Straight Leg Raise
 No tension until 30 degrees (stop @ 70)
 Tests (L4), L5, S1
 Positive if pain or paresthesia distal to
knee
 Compare seated to supine SLR
 Try with varying amounts of knee flexion
or ankle dorsiflexion
 Bowstring test-
squeeze popliteal
fossa
 Well leg SLR-pain
in affected side
 Femoral Stretch Test
 Pt supine or lateral
 Bend knee and extend hip
 L2/3/4
 Positive if pain to anterior or lateral thigh
 Spurling’s
 Axial Compression
 Extension
 Rotation to affected
side
 Positive if radicular
symptoms
 Cervical Provacative Tests
 Compressive
– Tighten foramina
– Positive if radicular
 Distraction
– Positive if radicular symptoms abate
 Shoulder abduction test
– Less tension decreases symptoms
 Kernig Test
 Forced
flexion
while
supine
 Locate Pain
 Stretches
cord
 Naffziger test
 Increase
intrathecal
pressure
 Gentle
compression of
jugulars for 10
sec
 Pt coughs
 Also use
Valsalva
Milgram Test
 Hold feet 2 inches
off table for 30
seconds
 Raises intrathecal
pressure
 Positive if pt can’t
do or if pain
 Suggests pressure
on cord or
intrathecal
pathology
 Sacroiliac Disease
Pelvic Rock Test
 Compress iliac wings
to midline
 Elicit pain in SI joints
 Patrick or Faber test
 Elicit pain in hip or SI
joint
 Flexion
 ABduction
 External Rotation
Gaenslen’s Sign
 Buttock and leg hang
off table
 Positive if pain around
SI joint
 Nonorganic Signs
 Waddell Signs
– Tenderness
 Superficial, nonanatomic
– Simulation
 Axial loading (LBP), rotation
– Distraction
 Straight leg raising (sitting v. supine)
– Regional
 Weakness; sensory loss that is nonanatomic
– Overreaction
Hoover’s Test
 References
 Frymoyer JW and Wiesel SW. The Adult
and Pediatric Spine. Third Ed. LWW,
Philadelphia. 2004.
 Hoppenfeld S. Physical Examination of
the Spine and Extremities. Appleton
and Lang, Norwalk, CT. 1976.
 Question one
 Based on the sagital and axial MRI scans
shown, the patient most likely has which
of the following clinical findings?
1. Hip flexor weakness
2. Quad and tibialis anterior weakness
3. EHL and hip abductor weakness
4. Plantar flexion and eversion weakness
5. Cauda equina syndrome
Question one
 Hint
 Far lateral L4/5 herniation
 Quadriceps and tibialis anterior weakness
 Question two
 A 42 year old man has severe low back pain,
urinary retention, and saddle anesthesia. His
medical history is unremarkable. What is the
most likely diagnosis?
1. Spondylolisthesis
2. Cauda equina syndrome
3. Peripheral neuropathy
4. Herpes zoster infection
5. Cervical myelopathy
 Cauda equina syndrome
 Question three
 In distinguishing patients with vascular
claudication from those with neurogenic
claudication (spinal stenosis), patients with the
latter condition are most likely able to
1. Walk downhill better than uphill
2. Stand for extended periods
3. Shop without a grocery cart
4. Predict their walking distance
5. Ride a stationary bicycle
 Ride a stationary bicycle
 Question four
 The triceps reflex is largely a function of
what neurologic level?
1. C5
2. C6
3. C7
4. C8
5. T1
 C7
 Question five
 A patient has a left-sided far lateral disk
herniation of an L4-5 level that is confirmed by
an MRI scan. Physical examination will most
likely reveal absence of the
1. Achilles reflex and difficulty with toe walking
2. Achilles reflex and difficulty with heel walking
3. Achilles reflex and difficulty with squatting
4. Patella reflex and difficulty with squatting
5. Patella reflex and difficulty with toe walking
 Patella reflex and difficulty squatting
 Question six
 Which of the following findings is more suggestive of
vascular rather than neurogenic claudication in the
differential diagnosis of leg pain?
1. Weakness of EHL
2. Normal hair pattern on both feet
3. More difficulty standing upright and walking down an
incline
4. Pain that begins in the buttocks and radiates distally
with further walking
5. Pain that is relieved by stopping and standing still
 Pain that is relieved by stopping and
standing still