History and Physical Examination of the Spine

Chapter Clinical Summary

The comprehensive evaluation of a patient presenting with spinal complaints begins well before reviewing neuroimaging studies. Formulating a precise clinical differential diagnosis before analyzing radiographic images prevents the common pitfall of treating incidental, asymptomatic imaging abnormalities (such as disc bulges or asymptomatic herniations found in up to 30–50% of healthy individuals). Axial back/neck pain, radiating radicular pain, progressive spinal deformity, and functional disability constitute the cardinal complaints, but each requires meticulous characterization regarding onset, duration, mechanical versus inflammatory features, red flags (fever, unexplained weight loss, nocturnal unremitting pain, history of malignancy, progressive neurological deficit), yellow flags (psychosocial distress, maladaptive illness behavior), and impact on activities of daily living. Physical examination must be global and systematic: inspecting posture, sagittal/coronal alignment, gait dynamics, skin stigmata, and pelvic/hip joints (hip-spine syndrome); performing targeted segmental motor (myotomes 0–5 MRC scale), sensory (dermatomes light touch and pinprick), and reflex testing (deep tendon reflexes, pathologic upper motor neuron signs like Babinski, Hoffmann, clonus); and conducting validated provocative orthopedic maneuvers (Spurling, Lhermitte, straight leg raise [Lasègue], femoral nerve stretch, Patrick FABER). In trauma, immediate life support is accompanied by standardized neurological assessment adhering strictly to the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI/ASIA scale).

To teach a comprehensive, reproducible, and structured sequence for the clinical and neurological examination of the spine. The reader should be able to conduct a targeted medical history; distinguish mechanical from neuropathic, vascular, and inflammatory pain patterns; evaluate spinal alignment, flexibility, and deformity; perform accurate segmental neurological examination (myotomes, dermatomes, reflexes); interpret validated cervical, lumbar, and sacroiliac provocative maneuvers; identify non-organic signs (Waddell signs); and apply standardized trauma examination principles including the ASIA impairment scale.

History taking begins with patient demographics, chief complaint, occupational and athletic demands, and detailed characterization of pain using the OPQRST mnemonic (Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Timing). Pain patterns must be differentiated: 1) Mechanical axial pain (aggravated by loading/motion, relieved by rest); 2) Radicular neuropathic pain (sharp, shooting, dermatomal radiation below the knee or elbow, associated with paresthesias); 3) Neurogenic claudication (buttock/thigh/calf cramping and heaviness provoked by walking and spinal extension, relieved by lumbar flexion/sitting—"shopping cart sign"); 4) Vascular claudication (fixed walking distance, relieved promptly by standing still, accompanied by diminished peripheral pulses and trophic skin changes); 5) Inflammatory pain (morning stiffness >30–60 min, improves with exercise, nocturnal awakening). Screen systematically for "Red Flags" (neoplasm, infection, fracture, cauda equina syndrome) and "Yellow Flags" (catastrophizing, depression, disability litigation).

Examination begins the moment the patient enters the room, assessing antalgic posturing, assistive devices, and gait dynamics (trendelenburg gait, steppage gait, spastic hemiparetic or scissoring gait, myelopathic broad-based ataxic gait). Spine inspection in standing position evaluates coronal plumb line balance (C7 plumb line over gluteal cleft), sagittal balance, shoulder level, pelvic obliquity, scapular asymmetry, and rib hump prominence on Adam's forward bend test (quantified with a Scoliometer). Palpate spinous processes for focal tenderness, step-off deformities (spondylolisthesis), and paraspinal muscle spasm. Measure active cervical and thoracolumbar range of motion in flexion, extension, lateral bending, and axial rotation.

Neurological localization requires rigorous assessment of motor, sensory, and reflex function: 1) Motor testing (0–5 Medical Research Council scale): C5 (deltoid/biceps), C6 (wrist extensors), C7 (triceps/wrist flexors), C8 (finger flexors), T1 (finger abductors), L2 (hip flexors), L3 (quadriceps), L4 (tibialis anterior/ankle dorsiflexion), L5 (extensor hallucis longus), S1 (gastrocnemius-soleus/plantarflexion); 2) Sensory testing: key dermatomal points from C2 to S4–S5 (light touch and pinprick); 3) Deep tendon reflexes: biceps (C5), brachioradialis (C6), triceps (C7), patellar (L4), Achilles (S1); and 4) Upper motor neuron/myelopathic signs: Hoffmann sign, inverted radial reflex, hyperreflexia, sustained ankle clonus (>3 beats), and Babinski sign.

Cervical tests: Spurling test (axial compression with ipsilateral neck extension and rotation, highly specific for cervical radiculopathy), shoulder abduction relief test (Bakody sign), neck distraction test, and Lhermitte sign (electric shock sensation down spine on flexion, indicating dorsal column pathology/myelopathy). Lumbar tests: Straight Leg Raise (SLR/Lasègue test: positive if radiating dermatomal pain reproduced between 30° and 70° of hip flexion), Bragard test (SLR + ankle dorsiflexion), Crossed Lasègue test (high specificity for herniated disc), and Femoral Nerve Stretch test (prone knee flexion, testing L2–L4 nerve roots). Evaluate the sacroiliac joint and hip to differentiate spine from hip pathology (hip-spine syndrome): Patrick FABER test, Gaenslen test, and hip internal/external rotation.

In acute trauma, vital stabilization (ATLS protocol) precedes spinal clearance. Document baseline neurological status using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI/ASIA): test 10 key motor muscle groups bilaterally (motor score 0–100), 28 key sensory dermatomes bilaterally for pinprick and light touch (sensory score 0–112 each), and perform digital rectal examination to determine sacral sparing (deep anal pressure [DAP] and voluntary anal contraction [VAC]). Sacral sparing defines an incomplete spinal cord injury (ASIA B, C, or D) versus complete injury (ASIA A), establishing fundamental prognostic expectations for functional recovery.

In routine outpatient practice, the clinical examination directs the diagnostic workup, preventing over-interpretation of incidental degenerative imaging findings. A patient with severe back pain and a large L4–L5 disc herniation on MRI whose neurological exam is completely normal and whose Lasègue test is negative is suffering from axial pain, not compressive radiculopathy, requiring conservative therapy rather than discectomy. Conversely, recognizing hyperreflexia, Hoffmann sign, and an ataxic gait in a patient presenting with vague hand numbness correctly diagnoses cervical spondylotic myelopathy, mandating urgent cervical decompression. In trauma, documenting sacral sparing (presence of voluntary anal contraction or deep anal sensation) is decisive: it proves an incomplete spinal cord injury with significant potential for neurological recovery, guiding aggressive surgical decompression and blood pressure augmentation protocols.

Selected Bibliographic References