The purpose of clinical examination are many. First and foremost, the identification of patients who need emergent or urgent care and treatment, and then, identify the cause of 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 fulfil the criteria of normality, reliability, validity, utility, compliance and cost effectiveness. (Waddell 1982)
Examination of spine involves 2 steps: history taking and physical examination. A detailed and chronological history and a structured clinical examination is 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 work-up, treatment options, follow-up, outcome analysis, prognostication and prevention.
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 allows 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 patient’s own everyday language. It should avoid medical terminology and inappropriate cultural assumptions (Waddell 1982). The information sought should be within patient’s knowledge.
History taking helps in localisation 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 neurone symptoms. Neurological symptoms may be sensory, motor or sphincter related.
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 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, tumours, 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 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, localised and worsened by activity. Visceral pain is poorly localised and not affected by activity or rest. Neurogenic pain is burning or pricking 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.
Site of pain is described as per the anatomic borders delineated by 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 fibres in a spinal nerve or its roots or other neuropathic mechanisms.”
- Duration – How long the pain is present?
- Onset- How did it start?
- Progress – What happened afterwards?
- 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?
- 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 spondylarthropathy.
- 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 spondylarthropathy.
- 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?
- Is there any associated symptoms?
- In girls presenting with spinal deformity, ask about age of menarche.
In the history, red flag and yellow flag signs which suggest serious underlying disease should be specifically looked for.
Red flag symptoms
Age > 50 years
Duration of symptoms > 1month
Significant neurological deficit
Progressive neurological deficit
Bowel or bladder disturbance
Unexplained weight loss
History of significant trauma
History of malignancy
History of steroid intake
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.
Development of secondary sexual characteristics using Tanner stages should be done in children with spinal deformity.
- 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.
- Pubertal hair development
- Breast development
- Stage I (Preadolescent) – Only the papilla is elevated above the level of the chest wall.
- 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.
- Pubertal hair development
- Pubertal hair development
- Stage II – Sparse long pigmented, slightly curled or straight, downy hair begins to appear.
- Male genitalia development
- Stage II – Enlargement of the scrotum and testes with changes in the texture of the scrotal skin.
- Stage V – Similar to adult in size and shape.
- Pubertal hair development
Signs of generalised ligamentous laxity
Neurocutaneous markers should be looked for in patients with scoliosis to rule out neurofibromatosis 1.
Upper segment : lower segment ratio
Inspection starts with assessment of the patient as a whole with 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.
- 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
- Spine of scapula – T3
- Inferior angle of scapula – T7
- Highest point of 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. 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.
- Head- Through the ear lobes
- Shoulders- Through the acromion.
- Thorax- Bisects the chest anteroposteriorly.
- Lumbar area- Midway between the lumbar spine and abdomen and slightly anterior to the sacroiliac joint.
- Hips- Posterior to the hip, through the greater trochanter.
- Knee- Slightly anterior to the centre of knee.
- Ankle- Just in front of lateral malleolus through the tuberosity of 5th metatarsal.
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.
To assess the posture and symmetry of spine ask the following questions.
From the front
- 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 thorax comparable on both sides?
- Is there abnormal prominence or concavity of sternum?
- Is the distance between the arms and trunk on both sides identical?
- Is 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 thoracic spine maintained?
- Is the normal lumbar lordosis present?
- Is there anterior or posterior tilting of the pelvis?
- How does the plumb line dropped from 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 dropped 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 the 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.
Spinal dysraphism is classified into occult (occulta) and open (operta). In the open type, there is a defect in the skin and posterior elements that exposes the neural elements. It includes myelomeningocoele, myelocoele, hemimyelomeningocoele and hemimyelocoele. Closed spinal dysraphism with subcutaneous mass are lipomas with subcutaneous mass such as lipomeningocoele, lipomyelomeningocoele etc. Most common site is lumbosacral.
A combination of 2 or more congenital midline cutaneous lesions is taken as strong sign of spinal dysraphism. Cutaneous lesions can be subcutaneous lipomas, dermal sinuses, tails and local hypertrichosis. 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 helps to narrow down the cause of pain. Tenderness on palpation of specific structures help in identification of pain generators. Palpation starts with feeling for 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.
Note the following points
- Location of apex
- 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 vertebra.
- Location of apex
- Side of convexity
- Largest curve
- Shoulder level
- Adams forward bending test
- Rib hump
- Loin hump
- Waist asymmetry
- Pelvic obliquity
- Head- Plumb line dropped from C7
- Trunk- Plumb line dropped from apex of the curve
- Flexibility of curve
- Push-prone test
- Side bending
Range of 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.
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 corocoid processes and the horizontal line. Measures the tilting of the shoulder due to coronal malalignment.
Angle of trunk inclination– Measured with the patient in forward bent position using an inclinometer. It is the angle between the horizontal reference line and the plane of greatest rib or lumbar hump. Measures the trunk asymmetry due to axial malrotation of 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 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 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. 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 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 upper most 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 iliac crest in the midaxillary line.
Instruments required- None.
Procedure- Measure the distance between the inferior margin of ribs and superior edge of 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 finger breadth 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 head against the wall, strigntening 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 specificity of 92% and 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.
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. Mold the flexible ruler to the spine. Place the ruler on the graph paper and trace the outline. Measure the length and width of thorax.
Interpretation- Kyphotic index is equal to thoracic width divided by thoracic length multiplied by 100. Clinical kyphosis is present if KI is > 13.
Straight leg raising test
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 Lasègue sign. He attributed the sign to be due to compression of 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 sciatic nerve.
Done with the patient supine. Raise the affected side with knee in extension. Positive if 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 thigh into the calf in the symptomatic side at 0-700 of limb elevation. It is a test of nerve root irritation. If patient complains of pain in the back or gluteal region, then the test is false positive.
It is highly sensitivity 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.
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 on to 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 SLR 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 forward 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 scoliosis, the test has a sensitivity of 0.83 and a specificity of 0.99.
Background- Described by William Adams in the 10th 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 Mentell: 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 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 localised 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 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 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 behaviour, 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 behavioural aspects of the illness also should be addressed. Waddell signs are associated with poorer treatment outcomes.
Complete neurological assessment should be done to identify any associated neurological deficit.
- Schober, P (1937) The lumbar vertebral column and backache. Munch. Med. Wschr. , 84,336.
- Moll JPH, Wright V. (1971) Normal range of spinal mobility: An objective clinical study. Ann. Rheum. Dis. 30, 381.
- Gordon Waddell, Chris J Main, Emyr W Morris, Robert M Venner, Peter S Rae, Samir H Sharmy & Helen Galloway.(1982) Normality and reliability of clinical assessment of backache. BMJ. 284. 1519-1523.