Neurological Examination of Spine

The purpose of clinical examination is many.  First and foremost, the identification of patients who need emergent or urgent care and treatment, and then, identify the cause of the patient’s symptoms, its impact on the patient, and the needs and expectations of the patient. Any associated medical conditions that have an impact on the treatment of the primary condition should also be identified. Proper physical examination achieves these objectives and allows the clinician to develop a healthy rapport with the patient as well.

The information generated from the history and examination must differentiate normal from abnormal, provide a reliable measure of the abnormality, and permit a valid interpretation. It should fulfill the criteria of normality, reliability, validity, utility, compliance, and cost-effectiveness. (Waddell 1982)

Examination of the spine involves 2 steps: history taking and physical examination. A detailed and chronological history and a structured clinical examination are essential for diagnosis. History taking provides information about the past and the present health status of the patient, his symptoms, and the disease. It helps in the assessment of disability caused by the disease. History provides the foundation for making decisions regarding the working diagnosis,  investigations needed for workup, treatment options, follow-up, outcome analysis, prognostication, and prevention.

History taking

History taking is an art. The clinician should learn to talk less and listen more. It should be detailed and chronological. History taking is divided into various components such as presenting complaint, history of presenting complaint, treatment history, past history, personal history, family history, occupational history, nutritional history etc. Depending on the setting of the patient interview, either some or all these components may have to be gone into.

History taking starts with simple, open-ended questions that allow the patient to communicate her perception of the problem and to let the surgeon understand the treatment goals. Later more focussed questions should be asked to get specific details about various aspects of the symptoms. The questions should be simple, clear, unambiguous and phrased in the patient’s own everyday language. It should avoid medical terminology and inappropriate cultural assumptions (Waddell 1982). The information sought should be within the patient’s knowledge.

History taking helps in the localization of the symptoms to the diseased part, discern the evolution of symptoms, identify the underlying pathology and elucidate the effect of the disease on the patient. It helps in identifying the associations and co-morbidities. The root cause of symptoms in spine patients may be vertebral, paravertebral, or referred. It may be musculoskeletal, neurological, or combined. Vertebral causes may present with pain, deformity, limitation of movement, swelling, or functional limitation. Neurological causes may present with upper motor or lower motor neuron symptoms. Neurological symptoms may be sensory, motor or sphincter related.

The most common presenting complaint is pain. Pain may be somatic, visceral, neurogenic, or psychosomatic. Somatic pain is due to local causes which can be mechanical or non-mechanical. Mechanical pain may be discogenic, capsuloligamentous, or stenotic in origin. Discogenic pain may be disco-dural or disco-radicular. Disco-dural pain presents with acute lumbago, chronic backache, or sciatica. Disco-radicular symptoms pain that radiating pain or neurological deficit in the body area supplied by the roots affected and occur when the neuronal cell bodies in the dorsal root ganglion situated within the intervertebral foramen are chemically or mechanically irritated by various causes; most commonly by a prolapsed disc. Mechanical causes of pain may be herniated nucleus pulposus, osteoarthritis, spinal canal stenosis, spondylolisthesis, or compression fracture. Non-mechanical causes may be inflammatory spondylarthritis, infective spondylitis, tumors, osteoporotic fractures, or visceral causes.

Pain due to spinal canal stenosis presents with unilateral or bilateral neurogenic claudication. Neurogenic claudication is worsened by standing or walking and is relieved by sitting, squatting, or stooping forwards. It is often associated with neurological symptoms such as weakness, numbness, or sphincter disturbance. Dural and root symptoms and signs are generally absent.

The cause of the pain may be identified from patient history based on the site of pain, onset, duration, radiation, relation to activity, and posture. Somatic pain is sharp, localized, and worsened by activity. Visceral pain is poorly localized and not affected by activity or rest. Neurogenic pain is burning or pricking the type of pain felt along the involved dermatomes. Psychosomatic pain is due to underlying psychological diseases and is a diagnosis by exclusion of other causes by detailed evaluation.

The site of pain is described as per the anatomic borders delineated by the International Society for Study of Pain (IASP). Low back pain as the site may be lumbar, sacral, coccygeal, loin, or gluteal pain.

According to the duration of symptoms, pain of duration less than 5 weeks is considered as acute, 5 weeks to 3 months as subacute, and more than 3 months as chronic pain. Radiculopathy is defined by IASP as “Pain perceived as arising in a limb or the trunk wall caused by ectopic activation of nociceptive afferent fibers in a spinal nerve or its roots or other neuropathic mechanisms.”

Pain history

• Duration – How long the pain is present?
• Onset – How did it start?
• Progress – What happened afterward?
• Site – Where do you feel the pain, point it out with a single finger?
• Character – What is the nature of pain? Is it throbbing, pricking, or burning type of pain?
• The intensity of pain – What is the severity of pain at present, at rest, and during activity? How severe was the worst pain you experienced?
• Temporal factors – Continuous or intermittent, diurnal variation.
  • Is the pain continuous or intermittent?
  • If intermittent, how long does each episode last?
  • If intermittent, is it colicky in nature?
  • Is there any relation between the severity of pain and the time of day?
  • Is there any sleep disturbance due to pain?
• Aggravating factors.
  • Is it aggravated by activity? Suggestive of mechanical pain.
  • Is it aggravated when getting up in the morning? If yes, how long does the increased pain last? Morning stiffness is present if the pain lasts for more than one hour. Morning stiffness is suggestive of inflammatory spondyloarthropathy.
  • Is it aggravated by walking? Suggestive of vascular or neurogenic claudication.
  • Is it aggravated by standing? Suggestive of neurogenic claudication.
• Relieving factors.
  • Is it relieved by activity? Suggestive of inflammatory spondyloarthropathy.
  • Is it relieved by rest? Suggestive of mechanical pain.
  • If aggravated by walking, is it relieved by standing? Suggestive of vascular claudication.
  • If aggravated by standing and walking, is it relieved by sitting down or stooping forwards? Suggestive of neurogenic claudication.
• Associated symptoms.

History taking in spinal deformity

• When was the deformity noticed?
• How was the deformity noticed?
• What happened to the severity of deformity after it was noticed?
• Is it painful?
• Is there any difficulty in walking?
• Is there any weakness or numbness in the upper or lower limbs?
• Is there any urinary retention or urinary incontinence?
• Is there any bowel complaints?
• Is there any exercise intolerance or exertional dyspnoea?
• Are there any associated symptoms?
• In girls presenting with spinal deformity, ask about age of menarche.

In history, red flag and yellow flag signs which suggest serious underlying disease should be specifically looked for.

Red flag symptoms

Yellow flag symptoms

• Denotes negative psychosocial factors that are associated with chronicity and long term disability. It may be related to work, beliefs, behaviour or affective disorders.

General Examination

Development of secondary sexual characteristics using  Tanner stages should be done in children with spinal deformity.

Tanner stages

• Used to assess sexual age by assessing the onset and progression of pubertal changes.
• Boys and girls assessed on a 5-point scale.
• Boys are assessed by genital development and pubic hair growth, and girls by breast development and pubic hair growth.
• Girls
  • Pubertal hair development
    • Stage I (Preadolescent) – Vellos hair develops over mons pubis similar to that over the anterior abdominal wall. There is no sexual hair.
    • Stage II – Appearance of sparse, long, pigmented, downy, straight or only slightly curled hair mainly along the labia.
    • Stage III – Appearance of darker, coarser, and curlier sexual hair appears sparsely over the junction of the pubes.
    • Stage IV – The hair distribution similar to adult but decreased in total quantity. No spread to the medial surface of the thigh.
    • Stage V – Pubic hair similar to adults in quantity and appearance.  Distribution have an inverse triangle and extends to the medial surface of the thighs. No extension above the base of the inverse triangle.
  • Breast development
    • Stage I (Preadolescent) – Only the papilla is elevated above the level of the chest wall.
    • Stage II – (Breast Budding) – Elevation of the breasts and papillae above the level of chest wall may as small mounds along with increase in the diameter of the areolae.
    • Stage III – The breasts and areolae continue to enlarge, and show no difference in contour.
    • Stage IV – The areolae and papillae form secondary mounds above the level of breast.
    • Stage V – Mature female breasts have developed. The papillae project due to recession of the areolae.
• Boys
  • Pubertal hair development
    • Stage I (Preadolescent) – Only vellos hair over the pubes similar to that over the abdominal wall is present.
    • Stage II – Sparse long pigmented, slightly curved or straight, downy hair begins to appear.
    • Stage III –  Darker, coarser, and curlier pubic hair with its distribution spread over the junction of the pubes.
    • Stage IV – Adult type hair distribution but quantity less. No spread to the medial surface of the thighs.
    • Stage V – Adult type hair distribution in an inverse triangle shape with extension to the medial thigh. Quantity and type are similar to adult.
  • Male genitalia development
    • Stage I (Preadolescent)- The testes, scrotal sac, and penis similar to early childhood in size and proportion.
    • Stage II – Enlargement of the scrotum and testes with changes in the texture of the scrotal skin.
    • Stage III – Along with increased growth of the testes and scrotum, there is the growth of the penis mainly in length, with some increase in diameter.
    • Stage IV – Penis and glans penis significantly enlarged in length and diameter. Testes and scrotum enlarge further with darkening of the scrotal skin.
    • Stage V – Similar to adult in size and shape.
• Facial hair
• Voice change
• Signs of generalised ligamentous laxity
• Neurocutaneous markers should be looked for in patients with scoliosis to rule out neurofibromatosis 1.
• Height
• Sitting height
• Upper segment: lower segment ratio
• Arm span

Inspection

Inspection starts with an assessment of the patient as a whole with the observation of his posture, demeanour,  and gait. Next inspect the entire vertebral column from the front, sides and back. Inspection should be done with the patient standing, sitting, supine and prone. First assess the surface anatomy of the spine.

Surface markings

• First palpable spinous process – C2
• Hyoid – C3
• Adam’s apple – C4/5
• Cricoid cartilage – C6
• Carotid tubercles (Chassaignac tubercle) – C6
• Most prominent spinous process- C7
• Longest spinous process – T1
• Sternal notch – T3/4
• The spine of the scapula – T3
• Inferior angle of scapula – T7
• The highest point of the iliac crest – L4/5
• Posterior superior iliac spine – S2

Assessment of posture

Spinal deformity is defined as a deviation from normal spinal alignment. Deformity should be defined in relation to the ‘neutral upright spinal alignment’ in asymptomatic individuals. Neutral upright spinal alignment (NUSA) position in asymptomatic individuals is determined with the patient standing with the knees and hips comfortably extended, the shoulders neutral or flexed, the neck neutral, and the gaze horizontal. If there is a limb length discrepancy of >2cm, it should be corrected by using blocks.

Assess the posture first and then look for deformities and how it is compensated. The deformity is assessed by asking the patient to stand in the NUSA position and in the forward bend position. Look for any deviation from normal and for asymmetry. In addition to deformity, look for how it is compensated either fully or partially. If alignment changes in one region, then the region above and below will develop compensatory changes to maintain global spinal alignment. Alterations and compensations can happen in the sagittal and coronal planes. Compensatory movements can occur at the hip also.

Stand on the side of the patient at a distance to get a lateral view of the patient. Drop an imaginary plumb line from the ear of the patient; the following is the normal alignment in the sagittal plane on the lateral view with regard to the plumb line.

Stand behind the patient to have a posterior view. On the posterior view, the plumb line passes normally as follows.

• Head – Bisects the head through the external occipital protuberance
• Shoulders – Midway between the shoulders.
• Trunk – Bisects the trunk
• Pelvis – Through the gluteal cleft.
• Knee – Equidistant from both knees.
• Ankle – Equidistant from both malleoli.

• Are the eyes at the same level?
• Are the ears at the same level?
• Is the nose in the midline?
• Is there tilting of the head?
• Is the head turned to one side?
• Is the prominence of both sternocleidomastoids identical?
• Is the concavity of both supraclavicular and infraclavicular fossa comparable?
• Are the shoulders level?
• Are the nipples at the same level?
• Is the shape of the thorax comparable on both sides?
• Is there abnormal prominence or concavity of the sternum?
• Is the distance between the arms and trunk on both sides identical?
• Are the anterior superior iliac spines at the same level?

From the sides

• Is the head tilted anteriorly or posteriorly?
• Is the head held anteriorly or posteriorly?
• Is the neck curvature normal in the sagittal plane?
• Does the ear lobes and acromion lie in the same line?
• Is there anteroposterior widening or narrowing of the thorax?
• Is the normal kyphosis of the thoracic spine maintained?
• Is the normal lumbar lordosis present?
• Is there anterior or posterior tilting of the pelvis?
• How does the plumb line drop from the ear pass in relation to the shoulder, trunk and lower limb joints?

From the back

• Is there tilting of the head?
• Is the head turned to one side?
• Is the prominence of paravertebral muscles identical?
• Is there periscapular wasting?
• Are the scapulae level?
• Are the iliac crests at the same level?
• Is there a rib hump?
• Is there abnormal prominence of spinous processes?
• Is the distance between the arms and trunk on both sides identical?
• Is the normal curvature of the spine maintained?
• How does the plumb line drop from the external occipital protuberance pass in relation to the shoulders, trunk and gluteal cleft?

Florence Peterson Kendall author of ‘Muscles: Testing and Function with Posture and Pain described Kendall’s postural types. 

• Kyphosis-lordosis posture– Head held forwards, neck hyperextended, thoracic spine in long kyphosis, lumbar spine lordotic, pelvis tilted anteriorly, hips flexed and knees hyperextended.
• Swayback posture– Head held forwards, neck hyperextended, thoracic spine in long kyphosis, lumbar spine flattened or slightly flexed, pelvis tilted posteriorly, hips hyperextended, knees hyperextended and ankle in neutral.
• Military type posture– Head neutral, neck straight, thoracic spine neutral or flattened, lumbar spine hyperextended, pelvis tilted anteriorly, knees hyperextended and ankles slightly plantarflexed.
• Flatback posture– Head held forwards, neck slightly extended, upper thoracic spine flexed, lower thoracic spine and lumbar spine flattened, pelvis tilted posteriorly, hips extended, knees hyperextended with plantarflexed ankles or knee flexed with ankle in dorsiflexion.

Swelling

Muscle wasting

Cutaneous abnormalities

• Spinal dysraphism is classified into occult (occult) and open (opera). In the open type, there is a defect in the skin and posterior elements that exposes the neural elements. It includes myelomeningocele, myelocoele, hemimyelomeningocoele and hemimyelocoele. Closed spinal dysraphism with subcutaneous mass are lipomas with subcutaneous mass such as lipomeningocoele, lipomyelomeningocoele etc. The most common site is the lumbosacral.
• A combination of 2 or more congenital midline cutaneous lesions is taken as a strong sign of spinal dysraphism. Cutaneous lesions can be subcutaneous lipomas, dermal sinuses, tails and local hypertrichosis. The most common cutaneous sign is a sacral dimple. Sacral dimple can be simple or atypical. Simple dimple is <0.5mm in diameter and <2.5cm closer to the anus. Atypical dimple is >5mm in size and >2.5cm from the anus. A flame-shaped hairy patch may be seen which is called faun tail.

Palpation

Palpation helps to narrow down the cause of pain. Tenderness on palpation of specific structures helps in the identification of pain generators. Palpation starts with a feeling for the local rise of temperature with the dorsal aspect of fingers. Palpate the superficial structures first and then the deeper structures. Identify the bony landmarks. During palpation, look for tenderness, bony abnormalities or bone defects.

Deformities

Note the following points

Kyphosis

• Location of apex
• Extent
• Compensatory lordosis above and below
• Knuckle type – Prominence of a single spinous process due to collapse of a single vertebra.
• Angular type- Collapse of 2-3 vertebra.
• Rounded type- Collapse of several vertebrae.

Scoliosis

• Tenderness
• Skin
• Range of movements

Movements

Assess the range of movements in the whole of spine. Aggravation of pain in the lower limbs during extension and relief with flexion indicates spinal stenosis. Aggravation of pain during flexion and relief with extension indicates disc disease.

Measurements

• Inter-pupillary angle– Angle between the inter-pupillary line drawn between the pupils and the horizontal reference line. Measures tilting of the head due to coronal malalignment.
• Shoulder tilt angle – Angle between the line drawn between the right and left coracoid processes and the horizontal line. Measures the tilting of the shoulder due to coronal malalignment.
• The angle of trunk inclination– Measured with the patient in forwarding bent position using an inclinometer. It is the angle between the horizontal reference line and the plane of the greatest rib or lumbar hump. Measures the trunk asymmetry due to axial malrotation of the vertebra.
• Chin-Brow vertical angle– Measures the angle between a line connecting the chin to the forehead with the vertical line when the patient is viewed from the side. it assesses the coronal malalignment. Normally the lines are parallel.
• Pelvic Obliquity– The angle subtended between the horizontal reference line and the line connecting the top of iliac crests or the ASIS on boot sides.
• Lumbar Lordosis– Keep a tape-measure tensed between thoracic and sacral prominences when the patient is standing erect. If the maximum distance between the tape measure and the concavity of the lumbar spine is less than 2cm then the lumbar lordosis is reduced. (Waddell 1982)
• Sciatic list– Drop a plumb line from the lower thoracic convexity and measure the offset from the gluteal cleft. (Waddell 1982)
• Lateral flexion– Mark the point in the midaxillary line at the level of a dimple of Venus. Mark the second pint in the midaxillary line 10cm above the first mark. Ask the patient to lateral flex to the opposite side. The normal range is at least 3 cm increase in the distance between the 2 lines. (Waddell 1982)

Modified Schober test (Moll 1971)

Schober described the test in 1937. It was modified by Moll and Wright of the Arthritis research unit of Leeds in 1971 as follows.

• Patient position – Standing.
• Examiner position – On the back of the patient.
• Instruments required – Measuring tap, skin marking pen.
• Procedure – 3 marks are made. First, at the lumbosacral junction represented by a line connecting the dimple of Venus on either side. Second, 5 cm below the first line and third, 10 cm above the first line. Keep the measuring tape at the uppermost mark. Make sure that the distance between the uppermost and lowermost markings is 15cm. Ask the patient to touch the toes without bending the knee. Measure the distance between the uppermost and lowermost lines.
• Interpretation – Normal excursion should be more than 5 cm.

Rib-pelvis distance test

• Patient position – Standing with the upper limbs raised in front to the horizontal position.
• Examiner position – Standing behind the patient with his hands insinuated between the inferior margin of ribs and superior edge of the iliac crest in the midaxillary line.
• Instruments required – None.
• Procedure – Measure the distance between the inferior margin of ribs and the superior edge of the iliac crest in fingerbreadths.
• Interpretation – Distance of two fingerbreadths or less is considered positive for kyphosis due to osteoporotic vertebral compression fractures.  Distance less than one fingerbreadth is 88% sensitive and 46% specific for osteoporotic vertebral compression fractures.

Wall-occiput distance test

• Patient position – Standing with the back to the wall and the heels touching the wall .
• Examiner position – Standing on the side.
• Instruments required – Measuring tape.
• Procedure – Ask the patient to put the back of their head against the wall, straightening up as much as possible with the eyes level. Measure the distance between external occipital protuberance and the wall.
• Interpretation – Inability to touch the wall is positive for kyphosis due to osteoporotic vertebral compression fractures. WO-Distance increases by 1.3cm for every osteoporotic vertebral compression fracture. WOD of 4cm had a specificity of 92% and a sensitivity of 41% for osteoporotic vertebral compression fracture. WOD of more than 6 cm had an odds ratio of 17.8 for osteoporotic vertebral compression fracture.

Kyphotic index

• Patient position – Standing in the best upright position.
• Examiner position – Standing behind the patient.
• Instruments required – Skin marking pen, flexible ruler, graph paper.
• Procedure  – Mark C7 and the lumbosacral junction. Mould the flexible ruler to the spine. Place the ruler on the graph paper and trace the outline. Measure the length and width of the thorax.
• Interpretation – Kyphotic index is equal to thoracic width divided by thoracic length multiplied by 100. Clinical kyphosis is present if KI is > 13.

Special Tests

Neck pain maneuvers

• Spurling’s maneuver – By turning your head and gently applying pressure, your doctor may reproduce radiating, nerve-related neck pain.
• Manual neck distraction test – This test will help identify nerve pain in your neck. Your doctor will ask you to lift your head, which may relieve pressure on compressed nerves.

Low back and leg pain maneuvers

• Femoral stretch test – While lying face down, your doctor will flex each knee to determine if you feel pain in your thigh. If you do, this indicates nerve compression in your lumbar spine.
• Schober test – This test examines the range of motion in your lumbar spine. During this test, you will bend over, as if you are trying to touch your toes.
• Trendelenburg test – This test can identify weakness in the muscles that support the hip. In this test, you’ll stand straight on one leg for 30 seconds. Your doctor will observe if your pelvis stays level.

Provocative Tests in a Spinal Examination

• Shoulder Abduction (Relief) sign – Active abduction of symptomatic arm achieved by patient placing their ipsilateral hand on their head. A positive test results in relief (or reduction) of cervical radicular symptoms.
• Neck Distraction test – Active distractive force is applied by examiner while grasping patient’s head under the occiput and chin. A positive test results in relief (or reduction) of cervical radicular symptoms.
• L’hermitte’s sign – Examiner passively flexes patient’s cervical spine. A positive test result is an electric shock-like sensation down spine or extremities.
• Hoffman’s sign – Passive snapping flexion of distal phalanx of patient’s middle finger. A positive test results in flexion-adduction of ipsilateral thumb and index finger.
• Adson’s test – Patient is instructed to inspire with chin elevated, and head rotated to the affected side. A positive test results in obliteration of radial pulse.
• The Spurling Test – is designed to reproduce symptoms by compression of the affected nerve root. The cervical extension is used to induce/reproduce posterior bulging of the intervertebral disk. Rotation of the head causes narrowing of the neuroforamina in the cervical spine. Finally, axial compression is applied to amplify these effects with the aim of exaggerating the preexisting nerve root compression.
• The prone instability test – The patient starts by standing on one end of the examination couch. While continuing to stand on the foot end of the couch, the patient lowers his / her torso on to the couch.  The patient can hold onto the couch’s sides for support. The examiner then palpates the lower lumbar spine to elicit tenderness. The patient then holds onto the couch and lifts his / her feet off the ground tensing the paraspinal muscles. Less pain and tenderness on repeat palpation of the lower lumbar spine while the feet are off the floor is considered positive. [rx]
• Prone Plank/Bridge – The patient is prone and elevates his / her entire body off the couch/mat on forearms and tips of toes. The body should be parallel to the couch/mat. With adequate muscle strength, men should maintain this position for 124 +/- 72s and Women for 83 +/- 63s.[rx]
• Supine Bridge – The patient is supine and flexes the hip and knee to keep the feet flat on the couch/mat. The arms are flexed to position the hands beside the ears. The lower part of the torso and pelvis is lifted off the couch/mat, to maintain the trunk and the thigh in a straight line. With adequate muscle strength, men should maintain this position for 188 +/- 45s and Women for 152 +/- 30s. [rx]

Clinical Tests for Instability

• Aberrant movement on flexion-extension – The standard examination involves documenting the range of movement. The quantitative range of movement may not be as significant as the qualitative range of movement. The important feature of spinal instability is the aberrant motion that occurs when flexing and extending the spine. A catch, a painful arc, supporting the arms on the thighs, or a reversal of the lumbopelvic rhythm when standing from the flexed posture indicates instability.[rx]
• Passive lumbar extension test – The subject lies on the examination couch. The examiner passively lifts the lower limbs to a height of 30 cm from the coach while maintaining the knee in extension and applying gentle traction on the legs. A positive test is recorded if the patient complains of “pain in the lower back region” or complains of “heaviness in the lower back” or complains that, “the lower back is coming off.” These experiences should return to normal when the leg returned to the couch. The passive lumbar extension test has the highest combined sensitivity and specificity and may be comparable to radiological findings to identify lumbosacral structural instability.[rx]
• The prone instability test – The patient stands at the foot end of the examination couch. The patient then lowers his/her upper body to rest on the examination couch. The iliac crest should rest on the edge of the examination couch. The patient holds the sides of the examination couch for increased stability. In the first part of the test, the feet of the patient is resting on the ground. The examiner with the heel of his/her hand creates a small posterior to anterior trust at each segment of the lumbar spine. Pain, if experienced by the patient, is recorded. In the second part of the test, the patient is asked to lift the feet of the floor and steady himself /herself by holding onto the sides of the examination couch. The examiner again repeats the posterior to anterior trust with the heel of his/her hand at each lumbar segment. The test is positive if the pain created in the initial part of the test subsides when the extensor muscles of the spine are tensed by lifting the feet of the floor.[rx]

Clinical tests for endurance

• Sorensen test – The legs of the patient are strapped onto a low platform, which is only 25 cms above the floor.  The upper end of the iliac crest is aligned to the edge of the table. The upper torso rests on the floor. At the commencement of the test, the patient extends the spine and lifts the upper torso off the floor with the arms crossed across the chest and is asked to maintain the horizontal position. The record of the time, the patient can maintain this position is documented.  Normative values: Men 146 +/- 51. Women 189 +/- 60.[rx]
• Prone isometric chest raise – The patient lies prone on the examination couch with a pad underneath the abdomen and the arms along the sides. The patient is instructed to lift the upper trunk about 30 degrees from the table while keeping the neck flexed, and the intention is to hold the sternum of the surface of the couch. The clinician records the maximum time that the patient can hold this position. [rx]Normative values: Men 40 +/- 9. Women 52 +/- 18.[rx]
• Prone double straight leg raise – The patient lies prone on the examination couch with the hips extended and the hands underneath the forehead. The arms are perpendicular to the body. The patient is then requested to lift both the legs off the couch until the knee is cleared off the couch. The patient should maintain normal breathing during the entire test procedure. The examiner can monitor the knee clearance by sliding a hand under the knee. The clinician records the maximum time that the patient can hold this position. Normative values: Men 38 +/- 6. Women 35 +/- 5. The prone double straight leg raise has shown to have great sensitivity and specificity. [rx]
• Supine static chest raise – The patient lies supine on the couch with the legs extended. The hands are placed on the temples with the elbows pointing to the ceiling.  The patient is then instructed to lift the head, the arms and the upper trunk of the couch. The patient should maintain normal breathing during the entire test procedure. The clinician records the maximum time that the patient can hold this position. Normative values: Men 43 +/- 9. Women 32 +/- 5. [rx]
• Supine double straight leg raise – The patient lies supine with the legs extended, and the arms crossed in front of the chest. The pelvis is tilted forward to increase the lumbar lordosis. The patient is then requested to lift both the legs of the floor for 30 degrees while maintaining normal breathing during the entire test procedure. To monitor the pelvic tilt, the examiner can place one hand under the lumbar spine.  The clinician records the maximum time that the patient can hold this position. Normative values: Men 28 +/- 4. Women 28 +/- 4. [rx]
• Flexor endurance test – The patient is supine on the couch with the upper part of the body propped up on a support. The support is at an angle of 60 degrees. The legs are flexed so that the knee is at a 90-degree angle with the foot flat on the couch. The toes and feet are strapped to the couch to provide a counterbalance. In a modified procedure, the examiner sits on the edge of the couch and over the toes of the patient to provide a counterbalance. The arms are crossed across the chest towards the opposite shoulder. The support is moved back by 10 cms, and the patient is instructed to maintain the original position. The clinician records the maximum time that the patient can hold this position. Normal values: Men 144 +/- 76, Women 149 +/- 99 in normal subjects.[rx]
• Prone Plank/Bridge – The patient lies prone on a mat. Initially, the patient lifts his / her upper torso off the mat and steadies on the elbows and forearms. The elbow is directly below the shoulder, and the forearms are straight with hands in front of the elbow. The patient then lifts the pelvis off the mat. The body is now supported on the elbow/forearm and the tips of the toes. The patient maintains a rigid horizontal position parallel to the floor. The clinician records the maximum time that the patient can hold this position. Normative values: Men 124 +/- 72s, Women 83 +/- 63s.[rx]
• Supine Bridge – The patient lies supine with the legs flexed so that the knee is at a 90-degree angle, and the foot is flat on the couch but not touching each other. The elbows are bent, and the hands are placed on the ears. The patient then lifts the pelvis so that the shoulders, hips, and knees are in a straight line. A rigid position is maintained, and the clinician records the maximum time that the patient can hold this position. Normative values: Men 188 +/- 45s, Women 152 +/- 30s.[rx]
• Side Plank/Bridge – The patient lies on the side on a mat. The upper part of the body is lifted off the mat and supported on the elbow of the arm below. The opposite (upper) arm crosses across the chest onto the lower shoulder. The top foot is positioned in front of the lower foot. The patient is then instructed to lift the pelvis off the floor and to maintain the trunk and the legs in a straight line. A rigid position is maintained, and the clinician records the maximum time that the patient can hold this position. Normative values: Men 95 +/- 35s, Women 74 +/- 33s.[rx]:

Waddell signs include

• Superficial tenderness – The patient’s skin over a wide area of the lumbar skin is tender to light touch or pinch.
• Non-anatomical tenderness – The patient experiences deep tenderness over a wide area that is not localized to one structure and crosses over non-anatomical boundaries.
• Axial loading – Downward pressure on the top of the patient’s head elicits lumbar pain.
• Acetabular rotation – Lumbar pain is elicited while the provider passively and simultaneously externally rotates the patient’s shoulder and pelvis together in the same plane as the patient stands. It is considered a positive test if pain occurs within the first 30 degrees of rotation.
• Distracted straight leg raise discrepancy – The patient complains of pain during a straight leg raise during formal testing, such as when supine, but does not on distraction when the examiner extends the knee with the patient in a seated position.
• Regional sensory disturbance –The patient experiences decreased sensation fitting a stocking-like distribution rather than a dermatomal pattern.
• Regional weakness – Weakness, cogwheeling, or the giving way of many muscle groups that are not explained on a neuroanatomical basis.
• Overreaction – A disproportionate and exaggerated painful response to a stimulus that is not reproduced when the same provocation is given later. These responses can include verbalization, facial expression, muscle tension, or tremor.[trx],[rx]

Straight leg raising test

• The straight leg raising test was described by JJ First in his doctoral thesis in 1881. He attributed the test to his teacher Charles Lasègue, hence called the Lasègue sign. He attributed the sign to be due to compression of the sciatic nerve by the hamstrings. In 1884, de Beurmann in a cadaveric study identified the stretching of the sciatic nerve by straight leg raising and attributed the pain to the stretching of the sciatic nerve.
• Done with the patient supine. Raise the affected side with the knee in extension. Positive if the patient complains of pain in the back of thigh radiating into the calf.
• True positive SLR is exacerbation or reproduction of pain radiating along the back of the thigh into the calf in the symptomatic side at 0-700 of limb elevation. It is a test of nerve root irritation. If a patient complains of pain in the back or gluteal region, then the test is a false positive.
• It is highly sensitive for lower lumbosacral root compressions (0.80-0.97) but low specificity (0.40). Hence a negative SLR is more important clinically than a positive SLR.

Verification of SLR

• Verification of SLR done to differentiate between pain due to hamstring tightness and sciatica. Verification manoeuvre Do SLR. Flex the knee slightly when pain is produced, pain disappears the limb can be raised further. Pain persists if false positive.

Variants of SLR test

• Crossed SLR – Described by Fajersztan.  Raising of straightened contralateral limb produced symptoms on the symptomatic side. Has a high specificity of 0.90.
• Bragaard’s test– Described by Fajersztan. Do SLR. Lower the limb slightly when pain is produced, dorsiflex the ankle. Pain reproduced if positive.
• Bowstring test– Do SLR. Lower the limb slightly when pain is produced, Pain disappears. Press on the popliteal fossa. Pain reproduced if positive.
• Cross-over sign– Do SLR. pain radiates into the affected limb and the opposite limb. Indicates a midline lesion, severe enough to compress nerve roots on both sides.

Slump test

• Position of patient- Seated upright.
• Position of examiner- Standing on the side of the patient
• Procedure- Ask the patient to slump first. If pain is not produced then ask the patient to bring his head onto the chest, extend his knee and dorsiflex his ankle one step at a time.
• Interpretation- Provocative sciatica is taken as a sign of neuromenigeal irritation.
• Use- Used as an alternative for the SLR test.

Quadrant test

• Position of patient- Standing
• Position of examiner- Standing behind the patient
• Procedure- Keep one hand over the patient’s contralateral shoulder and apply axial pressure. Ask the patient to hyperextend, rotate and laterally flex to the contralateral side.
• Interpretation- Provocative pain is taken as a sign of lumbar instability.
• Use- Used if pain cannot be produced by forwarding flexion, lateral flexion etc.

Adams forward bending test

• Position of patient- Standing with feet together, knee extended.
• Position of examiner- Standing behind the patient first then in front of the patient.
• Procedure- Rule out limb length discrepancy. Ask the patient to bend forwards at the waist till the back is in the horizontal plane. Palms should be held together.
• Interpretation- If there is a rib or loin hump present, then there is structural scoliosis with rotation.
• Use- To differentiate between structural and non-structural scoliosis.
• Validity of test-  For a patient with 40⁰ structural scolioses, the test has a sensitivity of 0.83 and a specificity of 0.99.

Background- Described by William Adams in the 10^th lecture of 12 lectures delivered in the Grosvenor Place School of Medicine in 1860-61 called “Lectures on the pathology and treatment of lateral and other forms of curvature of the spine”. His attention was first drawn into the rotation of vertebral bodies in scoliosis in the post mortem he conducted in 1852 on Gideon Algernon Mantell: a surgeon, geologist and palaeontologist who was one of the first to describe the dinosaur fossils.

Waddell’s nonorganic signs

Described by Prof Gordon Waddell in 1980 to identify the nonorganic or psychological component of chronic back pain. Consist of 5 categories and 8 signs

Category 1- Tenderness

• Sign 1- Superficial tenderness: Skin over a wide area is tender to touch.
• Sign 2- Non-anatomical tenderness: Deep tenderness over a large area that is not localized to one anatomical structure and crossing into non-anatomical areas.

Category 2- Simulation tests

• Sign 3- Back pain on simulated tests for axial loading: Downward pressure over the top of the head elicits lumbar pain
• Sign 4- Back pain on simulated rotation of the hips: The shoulder and hip passively rotated together in the same plane with the patient standing. Considered positive if pain appears within 30⁰ of rotation.

Category 3- Distraction 

• Sign 5- Straight leg raise improves when the patient is distracted: Straight leg raising painful when in supine, but not positive when the knee is extended in the seated position when the patient is distracted.

Category 4- Regional disturbances

• Sign 6- Non-dermatomal sensory changes: Sensory loss over an area that is not in the dermatomal pattern.
• Sign 7- Non-anatomical distribution of weakness: Weakness that cannot be explained on a neuroanatomical basis.

Category 5- Overreaction

• Sign 8- Disproportionate and exaggerated painful response that cannot be reproduced when done later.

If three or more categories are positive then the finding is considered clinically significant. It suggests only symptom magnification or pain behavior but doesn’t rule out organic causes. Positive Waddell signs should not be considered as malingering or for secondary gain. It just indicates that in addition to treatment, the psychosocial and behavioral aspects of the illness also should be addressed. Waddell signs are associated with poorer treatment outcomes.

Tips for Success During Your Physical Exam

You may think your doctor is solely responsible for diagnosing the cause of your back or neck pain, but you also play an essential role. Think of the diagnostic process as a partnership between you and your medical team. The following tips will help ensure you’re upholding your end of the bargain:

• If you’re in pain, say it –  Don’t try to hide it, downplay it, or view it as complaining. If a maneuver during your physical exam creates pain, describe it to your doctor.
• Get detailed – Does your pain get better when you rest? Does it radiate down your leg when you walk for more than 5 minutes? There’s no such thing as too much information, so consider writing down specific facets of your pain and bringing the list to your appointment to give your doctor the full picture of your pain.
• Mention all your symptoms – Even if you think they are minor, subtle, or completely disconnected to your back or neck pain, mention any painful or out-of-the-ordinary symptoms to your doctor.
• Answer your doctor’s questions honestly – Telling your doctor the truth about your medical history and symptoms will help your doctor correctly identify the cause of your pain and craft a safe, effective treatment plan.