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Examination of the Spine

Neck and back pain are common presentations in primary care. Many cases of neck and back pain are due to
benign functional or postural causes but a thorough history and examination is essential to assess the cause
(see articles Low Back Pain and Sciatica, Thoracic Back Pain and Neck Pain), any associated psychological
difficulties (eg depression, anxiety or somatisation disorder), and any functional impairment, including restrictions
with work, leisure and domestic activities.

General examination of the spine

The examination should begin as soon as you first see the patient and continues with careful
observation during the whole consultation.
It is essential to observe the patient's gait and posture. Inconsistency between observed function and
performance during specific tests may help to differentiate between physical and functional causes for
the patient's symptoms.

Inspection
Examination of any localised spinal disorder requires inspection of the entire spine. The patient should
therefore undress to their underwear.
Look for any obvious swellings or surgical scars.
Assess for deformity: scoliosis, kyphosis, loss of lumbar lordosis or hyperlordosis of the lumbar spine.
Look for shoulder asymmetry and pelvic tilt.
Observe the patient walking to assess for any abnormalities of gait.

Palpation
Palpate for tenderness over bone and soft tissues.
Perform an abdominal examination to identify any masses, and consider a rectal examination (cauda
equina syndrome may present with low back pain, pain in the legs and unilateral or bilateral lower limb
motor and/or sensory abnormality, bowel and/or bladder dysfunction with saddle and perineal
anaesthesia, urinary dysfunction and bowel disturbances, and rectal examination may reveal loss of
anal tone and sensation).

Movement
The normal range of movements are outlined in the relevant sections below.
Examination of the spine must also include examination of the shoulders and examination of the hips
to exclude these joints as a cause of the symptoms.

Neurovascular examination
A thorough examination of sensation, tone, power and reflexes should be performed (see article on
Neurological History and Examination).
Always consider the possibility of acute spinal cord compression, which is a neurosurgical
emergency.
All peripheral pulses should also be checked as vascular claudication in the upper and lower limbs can
mimic symptoms of radiculopathy or canal stenosis (see articles on Cardiovascular History and
Examination and Examining the Pulse).

Psychosocial factors
The assessment should include psychological, occupational and socio-economic factors, which may
either play a role in the cause of back problems, or be severely adversely affected as a result of back
problems.
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Waddell's signs have been used to indicate non-organic or psychological component to chronic low
back pain: [1]
Superficial non-anatomical tenderness.
Overreaction.
Pain on simulated manoeuvres: pain on axial loading of skull, pain on passive rotation of
shoulders and pelvis.
Straight leg raise testing discrepancy: straight leg raising when sitting and when supine not
consistent; sitting test performed while distracting patient.
Non-physiological examination: non-dermatomal sensory loss, cogwheel or give-way
weakness

A full psychiatric assessment may be required.

Neck examination
Neck problems are common in general practice, either chronic discomfort, such as with cervical spondylosis, or
following acute trauma, eg whiplash injuries following road traffic accidents. Evaluation of any neurological
symptoms in the upper limbs must include an assessment of possible causes in the neck. Spinal cord
compression in the neck may lead to lower limb problems and abnormal gait, as well as bladder and bowel
disturbance.

Neck inspection
Deformity: may be seen in cervical spondylosis or acute torticollis.
Instability of the cervical spine: check that the patient can easily support their head (obvious if mobile
but instability may be missed in a supine patient).
Abnormal head posture may be due to neck problems but also other causes, eg weakness of the
ocular muscles.
Asymmetry, eg of scapulae, or supraclavicular fossae, eg Pancoast's syndrome due to a malignant
tumour at the apex of the lung.
Torticollis (affected side and chin often tilted to opposite side) or sternomastoid 'tumour' in infants.
Causes of acquired torticollis include upper respiratory tract infection, vertebral malalignment or
trauma.
Arms and hands: for wasting, fasciculation, motor abnormalities (tone, power), sensory deficits and
any indication of thoracic outlet syndrome (see articles on Neurological Examination of the Upper
Limbs and Cervical Disc Protrusion and Lesions).
Lower limb motor or sensory deficits may be caused by cervical spinal cord compression.

Neck palpation
Palpate for tenderness and masses:
Posterior in the midline.
Lateral.
Supraclavicular - cervical rib (see article on Cervical Ribs and Thoracic Outlet Syndrome),
lymph glands, tumours.
Anterior - including thyroid examination.

Midline tenderness in the cervical spine: may be due to supraspinous damage following whiplash
injuries or may also indicate more major neck trauma.
Midline tenderness localised to 1 space is common in cervical spondylosis.
Palpate lateral aspects of vertebrae for masses and tenderness (the most prominent spinous process
is T1).
Paraspinal tenderness radiating into trapezius is common in cervical spondylosis.
Crepitation: facet joint crepitus may be detectable with flexion and extension of the neck by either
palpation or auscultation on either side of cervical spine; facet joint crepitus is common in cervical
spondylosis.

Cervical movement
Flexion: normal range is 80° with chin able to touch region of sternoclavicular joint.
Extension: normal range 50°, so normal for full flexion to full extension is 130°, primarily involves the
atlanto-axial and atlanto-occipital joints.
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Lateral flexion: normal range is 45° to both sides; restriction of lateral flexion is common in cervical
spondylosis. Inability of lateral flexion without forward flexion at same time suggests atlanto-axial and
atlanto-occipital joint abnormalities.
Lateral rotation: normal range is 80° to both sides; normally just short of plane of shoulders at full
rotation. Rotation is restricted and painful in cervical spondylosis.

Neurological involvement
See article on upper limb examination (and dermatome diagrams in the article). Neurological features associated
with cervical radiculopathy: [2]

C5 nerve root:
Muscle weakness: shoulder abduction and flexion/elbow flexion.
Reflex changes: biceps.
Sensory changes: lateral arm.

C6 nerve root:
Muscle weakness: elbow flexion/wrist extension.
Reflex changes: biceps/supinator.
Sensory changes: lateral forearm, thumb, index finger.

C7 nerve root:
Muscle weakness: elbow extension, wrist flexion, finger extension.
Reflex changes: triceps.
Sensory changes: middle finger.

C8 nerve root:
Muscle weakness: finger flexion.
Reflex changes: none.
Sensory changes: medial side lower forearm, ring and little finger.

T1 nerve root:
Muscle weakness: finger abduction and adduction.
Reflex changes: none.
Sensory changes: medial side upper arm/lower arm.

Thoraco-lumbar spine examination

Low back pain is a very common presentation in general practice. Although the cause and severity of back
problems are often fairly clear, it is often essential to make a thorough assessment and detailed examination of
the back. A thorough examination of the lower limbs is essential (see article on Neurological Examination of the
Lower Limbs).

Inspection
Observe for abnormal gait and posture, which may provide clues as to the nature and severity of the
problem.
Superficial landmarks include:
T1 is the most prominent spinous process at the base of the neck.
T7/T8: lower border of scapulae.
L4: iliac crests.
S2: dimples at posterior superior iliac spines.

Assess curvature: kyphosis, scoliosis.

Ask the patient to bend forwards: postural scoliosis resolves; a structural scoliosis does not disappear
and therefore needs further assessment. A lumber scoliosis may be associated with a prolapsed
intervertebral disc. Disappearance of a scoliosis when sitting suggests that the scoliosis may be
secondary to shortening of a leg. Idiopathic scoliosis leads to short stature with the trunk short in
proportion to the limbs.
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Ask the patient to extend their lower back. An increased kyphosis which is regular and mobile is found
in postural kyphosis. Common causes of a fixed regular kyphosis are senile kyphosis (may be
associated with osteoporosis, osteomalacia or pathological fracture), Scheuermann's disease and
ankylosing spondylitis. Common causes of an angular kyphosis, with a gibbus or prominent vertebral
spine include fracture, tuberculosis or a congenital vertebral abnormality.
Lumbar curvature: flattening or reversal of the normal lumbar lordosis as in a prolapsed intervertebral
disc, osteoarthritis of the spine and ankylosing spondylitis. An increase in the lumbar curvature may be
normal or due to spondylolisthesis, or secondary to an increased thoracic curvature or a flexion
deformity of the hip.
Look for any other abnormalities, eg café-au-lait spots, which may suggest neurofibromatosis, a fat
pad or hairy patch suggestive of spina bifida, or scarring suggestive of previous thoracotomy or spinal
surgery.
Functional overlay:
Ask the patient to sit up on the couch. A genuine patient will have to flex the knees or they
will fall back on the couch with pain.
Axial loading: apply pressure to the head. Overlay is suggested if this aggravates the back
pain.

Palpation
Check for bone tenderness of the spine: tenderness may indicate serious pathology such as infection,
fracture or malignancy.
Ask the patient to lean forwards: tenderness between the spines of the lumbar vertebrae and at the
lumbosacral junction and over the lumbar muscles may occur with prolapsed intervertebral disc and
mechanical back pain.
Check for tenderness over the sacroiliac joints. This may also occur in cases of mechanical back pain
and with inflammation of the sacroiliac joints.
A palpable step at the lumbosacral junction may indicate spondylolisthesis.

Percussion
Ask the patient to bend forward. Lightly percuss the spine from the root of the neck to the sacrum.
Significant pain is a feature of infections, fractures and neoplasms.
An exaggerated response may be a feature of a non-organic problem.

Movements
Flexion:
Observe carefully as hip flexion can account for apparent motion in a rigid spine.
Flexion may be recorded by the distance between the fingers and the ground (most normal
people can reach within 7cm of the floor) or the level that the person can reach (eg mid-
tibia).
The overall flexion is due to a combination of thoracic, lumbar and hip movements, and
does not distinguish between them.
Schober's test:
When the spine flexes, the distance between each pair of vertebral spines
increases. Schober's test can be used to provide a quantitative evaluation of
flexion of the lumbar spine.
A tape with a 15 cm mark is placed vertically in the midline upwards from the
level of the dimples at the level of the posterior superior iliac spines). Mark the
skin at 0 and at 15 cm and then ask the patient to flex as far forward as they can.
Record where the 15 cm mark on the skin strikes the tape. The increased
distance along the tape is due only to flexion of the lumbar spine and is normally
about 6-7 cm (less than 5 cm should be considered as abnormal).
Flexion in the thoracic spine may be measured with the upper point 30 cm from
the previous zero mark. Thoracic flexion is normally only about 3 cm.

Extension:
Ask the patient to arch their back; pain and restricted extension is particularly common in
prolapsed intervertebral disc and spondylolysis.
Maximum range is thoracic 25° and lumbar 35°.
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Lateral flexion:
Ask the patient to slide their hands down the side of each leg in turn, and record the point
reached, either in centimetres from the floor or the position that the fingers reach on the
legs.
The contributions of the thoracic and lumbar spine are usually equal.

Rotation:
The patient should be seated and asked to twist round to each side.
The normal range is 40° and is almost entirely thoracic; lumbar contribution is 5° or less.
Performing the test with the patient's arms folded across their chest gives a more accurate
assessment.

Suspected prolapsed intervertebral disc

Straight leg raising:
Passively flex thigh with extended leg while patient is supine. Dorsiflexion of foot helps to
elicit pain. Stop when the patient complains of back or leg pain (hamstring tightness is not
relevant). The test is negative if there is no pain. Paraesthesiae or pain in root distribution is
very significant, indicating nerve root irritation.
A positive result on the same side as the pain is said to be about 80% sensitive but only
40% specific; a positive result with the unaffected leg is said to be only 25% sensitive but
75% specific.
Back pain suggests, but is not indicative of, a central disc prolapse, and leg pain suggests
a lateral protrusion. Pain must be below the knee if the roots of the sciatic nerve are
involved.
Lower the leg until pain disappears and then dorsiflex the foot. This increases tension on
the nerve roots, aggravating any pain or paraesthesiae (positive sciatic stretch test).

Bowstring test:
Once the level of pain has been reached, flex the knee slightly and apply firm pressure with
the thumb in the popliteal fossa over the stretched tibial nerve. Radiating pain and
paraesthesiae suggest nerve root irritation.

Lasegue's sign:
With patient supine and hip flexed, dorsiflexion of the ankle causes pain or muscle spasm
in the posterior thigh if there is lumbar root or sciatic nerve irritation.

Femoral stretch test:

With the patient prone and the anterior thigh fixed to the couch, flex each knee in turn. This
causes pain in the appropriate distributions by stretching the femoral nerve roots in L2-L4.
The pain produced is normally aggravated by extension of the hip.
The test is positive if pain is felt in the anterior compartment of thigh.

Neurological involvement
Test the patellar (L3, L4) and achilles (L5, S1) reflexes.
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Root pressure from a disc may affect myotomes and dermatomes in a selective fashion; record any
muscle wasting (compare girths of calf and thigh muscles):
Myotomes:
L2, L3: hip flexion and internal rotation
L4, L5: hip extension and external rotation
L3, L4: knee extension
L5, S1: knee flexion
L4, L5: ankle dorsiflexion
S1, S2: ankle plantar flexion
L4: ankle inversion
L5, S1: ankle eversion

Dermatomes:
L2: upper thigh
L3: knee
L4: medial aspect of the leg
L5: lateral aspect of the leg, medial side of the dorsum of the foot
S1: lateral aspect of the foot, the heel and most of the sole
S2: posterior aspect of the thigh
S3-S5: concentric rings around the anus, the outermost of which is S3

Suspected thoracic cord compression

Thoracic cord compression may be assessed by testing the abdominal reflexes. Use a blunt object to
stroke the skin in each paraumbilical skin quadrant.
Failure of the umbilicus to twitch in the direction of the stimulated quadrant suggests cord
compression on that side at the appropriate level.
The muscles of the upper quadrants are supplied by T7-T10, and the lower quadrants by T10-L1.

Suspected thoracic motor root dysfunction

Ask the patient to place their hands behind their head, flex their knees and sit up.
Movement of the umbilicus to one side suggests a weakness of the abdominal muscles on the
opposite side.
Possible causes of nerve root compression include an osteophyte, tumour or spinal dysraphism.

Chest expansion
Chest expansion may be particularly relevant in suspected cases of ankylosing spondylitis.
Check the patient's chest expansion at the level of the 4th interspace.
The normal range for an adult of average build is at least 6 cm.
Less than 2.5 cm is considered abnormal.

Abdominal and cardiovascular examination

Depending on individual presentation, it is essential to consider non-musculoskeletal causes of back
pain, eg urological, gynaecological, gastrointestinal, aortic aneurysm.
Assessment of peripheral vascular system in lower limbs may be important with patient presenting
with leg symptoms, to evaluate peripheral vascular disease.
Consider primary malignancy sites which may have metastasised to the spine, especially breast
cancer, thyroid cancer, renal cancer, prostate cancer and lung cancer.

Hip and sacroiliac joint examination

Check the hip joints for range of movement and for pain or limitation. Hip problems may present with
predominantly back and buttock pain as well as pain in the groin. A loss of range on internal rotation of
the hip is often the earliest sign of hip disease.
Osteoarthritis of the hip may be clinically confused with low back pain, particularly prolapsed
intervertebral disc.
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To assess the sacroiliac joint:
With the patient lying prone, elicit sacroiliac joint tenderness by applying firm pressure with
one hand over the sacrum and the upper natal cleft.
Then flex the hip and knee, and then adduct the hip. Pain may indicate sacroiliac joint
involvement, such as in ankylosing spondylitis or Reiter's syndrome.

Further reading & references

Neck pain - non specific, Clinical Knowledge Summaries (January 2009)
Low back pain; NICE Clinical guideline (May 2009)
Douglas G, Macleod J, Nicol F, Robertson C; Macleod's Clinical Examination 11th edition
McRae R; Clinical Orthopaedic Examination 5th edition
Back pain - low (without radiculopathy), Clinical Knowledge Summaries (November 2009)
Sciatica (lumbar radiculopathy), Clinical Knowledge Summaries (November 2009)

1. Waddell G, McCulloch JA, Kummel E, et al; Nonorganic physical signs in low-back pain. Spine (Phila Pa 1976). 1980 Mar-
Apr;5(2):117-25.
2. Neck pain - cervical radiculopathy, Clinical Knowledge Summaries (January 2009)

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Original Author: Current Version:

Dr Colin Tidy Dr Colin Tidy
Last Checked: Document ID: © EMIS
11/12/2009 1095 (v22)

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