The Neuromusculoskeletal Examination of the Spine

On Part III the spinal examination is never asked as a list of eponyms; it arrives as a patient who has already told you a story, and the item asks which test you would do next, what a positive result means, and whether this person can safely be treated. A good spinal examination is short, ordered by hypothesis and honest about what each test can and cannot prove. This chapter works through posture and gait, the cervical, thoracic and lumbopelvic regions, and segmental palpation the way the exam does: one case at a time, from the first clue to a working impression.

Section 1Posture and gait analysis in cases

Why posture and gait come first

Posture and gait are observed before the patient knows the examination has started: as they rise from the waiting room chair, walk down the hall and undress. That unguarded observation is often more honest than any provoked test. A patient who rises using the arms of the chair, walks with a shortened step and leans forward on the counter has told you about pain behavior, lower limb strength and perhaps lumbar stenosis before a single question about the back. The board uses posture and gait as the first clue in a vignette; your job is to translate the finding into a structure and then pick the test that confirms it.

Static posture

Static posture is assessed from behind, from the side and from the front, ideally against a plumb line or grid. From the side the ideal line falls through the external auditory meatus, the cervical vertebral bodies, the acromion, the lumbar vertebral bodies and the greater trochanter, then slightly anterior to the knee joint axis and slightly anterior to the lateral malleolus. From behind it bisects the occiput, follows the spinous processes and the gluteal cleft, and falls midway between the knees and the heels. Departures are described by region and direction, then explained by a mechanism.

• Anterior head carriage places the ear in front of the acromion. Each 2.5 cm of forward displacement roughly adds the weight of the head again to the load on the posterior cervical muscles, which is why these patients complain of suboccipital tension and headache.
• Upper crossed syndrome (Janda) pairs tight upper trapezius, levator scapulae and pectorals with weak deep neck flexors, lower trapezius and serratus anterior, giving forward head, rounded shoulders and scapular winging.
• Lower crossed syndrome pairs tight hip flexors and thoracolumbar extensors with weak abdominals and gluteus maximus, producing anterior pelvic tilt and increased lumbar lordosis.
• Flat back (loss of lordosis) is common with acute disc pain and protective spasm, and late in degenerative disease or after fusion. Sway back shifts the pelvis forward of the line with the thorax behind it.
• A lateral shift (list) of the trunk over the pelvis in acute low back pain usually reflects a posterolateral disc herniation. By convention the shift is named for the direction the shoulders move. A shift away from the painful side is classically associated with a herniation lateral to the nerve root, and a shift toward the painful side with an axillary (medial) herniation, although the rule is not reliable enough to diagnose from.
• Leg length inequality is measured with a tape. Anatomical (true) length runs from the ASIS to the medial malleolus; apparent (functional) length runs from the umbilicus to the medial malleolus. An unequal apparent length with equal true lengths points to pelvic obliquity, muscle imbalance or a lumbar curve rather than a short bone.

Scoliosis screening

From behind, look for shoulder height difference, scapular prominence, unequal space between the arm and the waist (the waist triangle), and a pelvis that is level with a trunk that is not. The Adams forward bend test separates structural from functional curves: the patient bends forward with knees straight and palms together while the examiner sights along the back from behind or in front. In a structural curve the vertebral bodies rotate toward the convexity, carrying the posterior ribs backward and producing a rib hump on the convex side; the spinous processes rotate toward the concavity. A functional (postural or compensatory) curve, for example from a leg length difference or muscle spasm, straightens or disappears in forward flexion and does not produce a rotational prominence. Seating the patient abolishes a curve caused by a short leg.

A scoliometer laid across the prominence measures the angle of trunk rotation. A reading of 5 degrees is the usual screening threshold and 7 degrees corresponds roughly to a Cobb angle of 20 degrees; at or above 7 degrees most guidelines recommend a standing PA radiograph. The most common pattern is a right thoracic curve in an adolescent girl. A left thoracic curve, a painful curve, rapid progression, or neurologic signs (abnormal abdominal reflexes, clonus, cavus foot) raise concern for an underlying cause such as syringomyelia, tethered cord or osteoid osteoma, and call for MRI and referral.

Gait analysis

The gait cycle runs from initial contact of one heel to the next initial contact of the same heel. Stance occupies about 60 percent of the cycle and swing about 40 percent. Each cycle contains two periods of double limb support, each about 10 percent, which disappear in running. Stance is subdivided into loading response, midstance, terminal stance and preswing; swing into initial swing, midswing and terminal swing. The timing matters because each deviation belongs to a phase: foot slap happens at loading response, a Trendelenburg drop at midstance, toe drag and steppage during swing.

Section 2Cervical examination in cases

Order of the cervical examination

Begin with safety, not provocation. Before any test that loads the neck, the history should already have screened for trauma that needs imaging (Canadian C spine rule or NEXUS criteria), inflammatory arthritis or Down syndrome (upper cervical ligament laxity), symptoms of myelopathy, and symptoms of cervical artery dysfunction. Then observe, take active range of motion, test neurologically, and only then use provocative and relieving tests chosen by the working hypothesis. A patient with a fracture risk is imaged first and examined later; a patient with signs of cord compression or dissection is referred, not provoked.

Range of motion

Commonly taught normal active ranges are flexion 50 degrees (chin nearly to chest), extension 60 degrees, lateral flexion 45 degrees and rotation 80 degrees to each side. About half of cervical rotation occurs at C1 on C2, and about half of flexion and extension at the occiput on C1 and in the lower cervical segments. Rotation limited mainly in flexion (the cervical flexion rotation test) isolates C1 to C2 and is a useful sign in cervicogenic headache, where rotation of less than about 32 degrees toward the painful side is considered positive. Record range, the pattern of restriction and what each movement reproduces. Pain on extension and ipsilateral rotation suggests facet or foraminal compression; pain on the opposite side with lateral flexion suggests muscle or ligament stretch. Loss of rotation of less than 60 degrees toward the symptomatic side is one item of the radiculopathy cluster.

Provocative and relieving tests for radiculopathy

No single test makes the diagnosis, which is why the Wainner cluster is so useful. Its four items are a positive upper limb tension test A, ipsilateral cervical rotation of less than 60 degrees, a positive distraction test and a positive Spurling test. With three of four positive the positive likelihood ratio is about 6; with all four it rises to about 30. The upper limb tension test, with its high sensitivity, is the best single test to rule radiculopathy out.

Myelopathy

Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction in older adults and is easy to miss because neck pain may be minimal. Clues are clumsy hands (difficulty with buttons and handwriting), a broad based or spastic gait, generalized rather than dermatomal numbness, and later bladder urgency. Lhermitte sign, an electric sensation down the spine or into the limbs on neck flexion, points to the cord itself: myelopathy, multiple sclerosis, or less commonly tumor or radiation injury. Long tract signs include Hoffmann sign (flicking the distal phalanx of the middle finger produces thumb and index flexion), the inverted supinator sign (tapping the brachioradialis tendon produces finger flexion with a reduced brachioradialis response, implying a C5 to C6 cord lesion), hyperreflexia below the level, clonus and a Babinski sign. A clinical cluster (gait deviation, positive Hoffmann, inverted supinator sign, positive Babinski and age over 45) gives a positive likelihood ratio of about 30 when three of five are positive, while one or fewer positive helps rule it out. Myelopathy is a reason to refer for MRI and surgical opinion and a contraindication to high velocity cervical thrust.

Upper cervical instability and cervical artery dysfunction

Ligamentous laxity at C1 to C2 is a concern in rheumatoid arthritis, Down syndrome, after upper cervical trauma, and with some congenital anomalies such as os odontoideum. Symptoms include a sense that the head is "heavy" or needs holding, occipital pain, paresthesia of the lips or face, and myelopathic signs. The Sharp Purser test is performed seated with slight neck flexion: the examiner stabilizes the C2 spinous process and presses the forehead posteriorly. A sliding sensation or relief of symptoms as the atlas reduces is positive (specificity about 0.96). Alar ligament stress tests feel for immediate C2 spinous process movement with side bending or rotation; delayed movement suggests laxity. These tests should be gentle, and a positive or suspicious finding means flexion and extension radiographs or MRI before treatment, not repeated testing.

Cervical artery dysfunction (vertebral or internal carotid artery dissection) usually presents with unusual, severe neck pain or headache that the patient calls new and different, sometimes after minor trauma, followed hours to days later by ischemic symptoms. The vertebrobasilar warning signs are remembered as the 5 Ds and 3 Ns: dizziness, diplopia, dysarthria, dysphagia, drop attacks, nausea, nystagmus and numbness (often facial or perioral), plus ataxia. Internal carotid dissection may add Horner syndrome, pulsatile tinnitus or cranial nerve palsies. Traditional positional tests (George, DeKleyn, Maigne, Hautant, Underburg) hold the neck in extension and rotation while watching for nystagmus or symptoms. They have poor sensitivity and do not predict who will be harmed, so a negative positional test never clears a patient. Screening rests on the history and a neurologic examination, including cranial nerves, coordination and blood pressure in both arms. A suspected dissection is an emergency referral.

Section 3Thoracic and rib examination in cases

Motion and rib mechanics

The thoracic spine is stiffened by the rib cage, so its motion is small: commonly cited values are flexion about 20 to 45 degrees, extension 25 to 45 degrees, lateral flexion 20 to 40 degrees and rotation 35 to 50 degrees, with rotation greatest in the upper and middle segments where the facets lie in a near coronal plane. Each typical rib articulates with two vertebral bodies at the costovertebral joint and with a transverse process at the costotransverse joint, so a painful rib and a painful thoracic segment are easily confused. Upper ribs move mainly in a pump handle pattern that raises the sternum anteriorly; lower ribs move in a bucket handle pattern that widens the lateral chest. A rib that stops moving early on inspiration is described as held in exhalation, and one that stops early on exhalation as held in inhalation.

Chest expansion is measured with a tape at the fourth intercostal space (the nipple line in men) from full exhalation to full inspiration. Expansion of less than about 2.5 cm is abnormal and, in a young adult with inflammatory back pain, suggests costovertebral involvement by ankylosing spondylitis. Restricted expansion also occurs with pleural disease, obesity, pain and chronic lung disease, so it is interpreted with the history.

Thoracic outlet tests

Thoracic outlet syndrome is compression of the brachial plexus, subclavian artery or subclavian vein at one of three sites: the interscalene triangle (anterior scalene in front, middle scalene behind, first rib below), the costoclavicular space between the clavicle and first rib, and the subpectoral space beneath the pectoralis minor near the coracoid. The plexus and subclavian artery pass through the interscalene triangle, while the subclavian vein passes in front of the anterior scalene. About 95 percent of cases are neurogenic, typically affecting the lower trunk (C8 and T1: ulnar side of the hand and forearm, intrinsic hand weakness). Venous cases (about 3 to 5 percent) present with arm swelling and cyanosis, often in a young athlete after overhead exertion (effort thrombosis, Paget Schroetter syndrome). Arterial cases (about 1 percent) present with coldness, pallor or digital ischemia and are often associated with a cervical rib.

Red flag thoracic pain

Thoracic pain carries a higher pretest probability of serious disease than neck or low back pain. The thoracic spine is the most common site of spinal metastasis (roughly 70 percent of spinal metastases), and many visceral organs refer pain to the interscapular region. Treat thoracic pain as mechanical only when it behaves mechanically: it should change with movement, posture and palpation, and should not be accompanied by systemic or visceral symptoms.

Section 4Lumbar and pelvic examination in cases

Motion and observation

Typical active lumbar ranges are flexion 40 to 60 degrees, extension 20 to 35 degrees, lateral flexion 15 to 25 degrees and rotation 3 to 18 degrees. Watch the quality of motion as much as its range: a painful arc, a deviation to one side during flexion, a reversal of the lumbopelvic rhythm on returning from flexion (the patient "climbs up the thighs" with the hands, a sign of instability or severe pain), and whether repeated movements centralize or peripheralize symptoms. Pain that centralizes, retreating from the leg toward the spine with repeated movement in one direction, predicts a good outcome with directional preference exercise. The modified Schober test marks the lumbosacral junction (the level of the dimples of Venus) and a point 10 cm above it; an increase of less than 5 cm on full flexion indicates restricted lumbar flexion and is a classic finding in ankylosing spondylitis.

The straight leg raise family and the slump

The sciatic nerve and the L4 to S1 roots glide 2 to 6 mm through the foramina as the hip flexes with the knee straight. A herniated disc tethers the root, so stretch reproduces radicular pain. In the straight leg raise (Lasegue) the examiner lifts the straight leg of the supine patient. Reproduction of the patient's radiating leg pain below the knee between about 30 and 70 degrees is positive. Below 30 degrees there is little root excursion, and pain then suggests acute inflammation, hip or sacroiliac disease, or nonorganic behavior; above 70 degrees the root is fully stretched and pain usually comes from hamstrings, the lumbar joints or the sacroiliac joint. Back pain alone or posterior thigh tightness is not a positive SLR.

The sacroiliac joint and the hip

Single sacroiliac tests and static or motion palpation of the joint are unreliable, but a cluster performs well. In the Laslett cluster five provocation tests are used: distraction (anterior gapping, pressure on both ASIS supine), thigh thrust (posterior shear through the femur with the hip flexed to 90 degrees), compression (side lying, pressure down through the iliac crest), sacral thrust (prone, pressure on the sacrum) and Gaenslen (one hip held in full flexion while the other is extended off the table). Three or more positive of five, or two of the first four, gives a sensitivity near 0.9 and specificity near 0.8 for sacroiliac pain. Thigh thrust is the most sensitive single test and distraction the most specific. The cluster is meaningful only when lumbar sources have been reasonably excluded, for example when repeated movements do not centralize the pain. Patrick (FABERE) places the heel on the opposite knee and lowers the flexed, abducted, externally rotated thigh: groin pain implicates the hip, while posterior pain at the joint implicates the sacroiliac joint. Yeoman extends the hip with the knee flexed, prone: sacroiliac pain suggests anterior sacroiliac ligament strain, anterior thigh pain suggests femoral nerve tension, and lumbar pain suggests a lumbar source.

Always screen the hip in "back pain" with buttock or groin pain. Loss of internal rotation is the earliest sign of hip osteoarthritis; groin pain on FADIR (flexion, adduction, internal rotation) suggests femoroacetabular impingement or a labral tear and is very sensitive; pain on the log roll is specific for an intra-articular source; the Thomas test shows hip flexor tightness when the extended thigh lifts off the table; Ely (prone knee flexion that raises the hip) shows rectus femoris tightness; Ober shows iliotibial band tightness. The Trendelenburg sign tests gluteus medius strength.

Nonorganic signs

Waddell signs fall into five categories: superficial or nonanatomic tenderness; simulation tests (low back pain with light axial loading of the head or with passive rotation of the shoulders and pelvis together); distraction (a markedly positive supine SLR but a normal seated SLR during apparent knee examination, the flip test); regional disturbances (giving way or sensory change that follows no root or nerve); and overreaction. Three or more positive categories is significant. The signs indicate psychosocial distress and predict poorer outcome and response to purely physical treatment; they do not prove malingering and do not exclude organic disease. The Hoover test adds evidence about effort: the examiner cups both heels while the supine patient tries to raise the affected leg; a patient who is genuinely trying presses the opposite heel down, and absence of that pressure suggests lack of effort.

Section 5Palpation and segmental examination

Static and motion palpation

Static palpation is performed with the patient still. It assesses skin temperature and moisture, soft tissue texture and edema, muscle tone (hypertonicity, taut bands and trigger points), tenderness, and bony alignment such as a rotated spinous process or a step off. A myofascial trigger point is a tender nodule in a taut band that reproduces a characteristic referred pain pattern and may give a local twitch response or a jump sign. A palpable step off at L5 on S1, with the spinous process above sitting forward, suggests spondylolisthesis.

Motion palpation assesses movement. Intersegmental range is felt as the patient or examiner moves the spine through flexion, extension, lateral flexion and rotation, and the examiner's contact tracks whether each segment moves as much as its neighbors. Joint play is the small, involuntary accessory movement available in a relaxed joint, and is assessed with gentle springing toward the end of passive range. A fixation (hypomobility) is a segment that lacks normal joint play or end range motion. The examiner notes the direction of restriction, which in chiropractic listings guides the line of drive.

End feel

End feel is the quality of resistance at the end of passive range, as described by Cyriax. Each normal joint has a characteristic end feel, and an end feel in the wrong joint or at the wrong point in range is pathological.

Reliability of palpation findings

Palpation is the most chiropractic of all examination skills and the least reliable between examiners, and the board expects you to know the evidence. Reliability is usually expressed with the kappa statistic, where 0 is chance agreement and values above about 0.4 are moderate and above 0.6 substantial. Pain provocation (tenderness on pressure) shows the best interexaminer agreement, typically moderate. Static assessment of soft tissue, and especially of bony position, is poor. Motion palpation for segmental fixation shows interexaminer kappa values near chance in most studies, while the same examiner agrees with himself better (intraexaminer reliability is fair to moderate). Regional range of motion with an inclinometer is reliable. Several practical rules follow: anchor a segmental finding to tenderness, confirm it with a second type of finding at the same level, use the patient's report of familiar pain, and do not stake a diagnosis on a single palpatory impression.

From findings to a segmental diagnosis: PARTS

The PARTS framework organizes the evidence for a segmental dysfunction (the chiropractic subluxation): Pain and tenderness, Asymmetry or misalignment, Range of motion abnormality, Tone, texture and temperature change in the soft tissues, and Special tests (such as provocation or instrumented tests). For third party documentation in the United States, a subluxation demonstrated by physical examination requires at least two of the four PART findings, one of which must be asymmetry or range of motion abnormality. Requiring agreement among several findings at the same level offsets the weakness of any single one.

Words worth knowing