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Spine History and Physical Examination

This section introduces you to the information spine specialists often collect about their patients to help them make a diagnosis.

A spine history and spine examination are done as the initial steps towards making a diagnosis. Usually this information is then combined with spine images (X-Rays, CT, MRI) for a complete picture, which is the diagnosis. The diagnosis is essential for choosing the right type of treatment for a patient.

A. Spine History

In addition to a complete medical history, spine specialists will ask you for a specific spine history. The spine history is very important since it is a diary of your symptoms. It may allow the spine specialist to narrow your diagnosis down and be able to ask specific follow-up questions.

Here are some of the commonly asked questions:

Do you have back or leg pain, numbness or weakness, or a combination of these?

This is important for the spine specialist since it provides some idea if they are dealing with nerve inflammation, nerve irritation or nerve compression of a spinal nerve.

Where is your pain located?

A spine specialist will have you fill out paperwork where you may find an outline of the human body and asked to make a mark where you experience pain. It is important to mark all the areas. For instance, you may have pain in the low back which travels to the leg. So, both the back and leg have to be marked.

How severe is your pain?

There may be a scale from 0-10 where you can circle the number of how much pain you are experiencing. These scales are often used in several parts of the pain diary, often associated with different activities. It is important to know which activities are causing the most pain.

How often do you have pain?

Here you want to indicate when or with what activities you experience pain. For example: My pain is worst in the morning…

How is the pain impacting on your ability to function?

Here you may want to list certain activities which cause you difficulty. For instance, lifting objects, stair climbing, walking a certain distance, etc.

How long have you had this pain?

How long you have had pain is important. This helps the spine specialists to understand if you have an acute or chronic problem. Pain experienced daily for over 6 months is typically called chronic.

Is your pain getting better, staying the same, or getting worse?

It is important to know which way the pain is trending. Is it escalating or diminishing?

What makes your pain worse, sitting, standing, walking, bending, lifting, coughing, sneezing, lying down?

This information often points towards a specific spine problem such as a herniated disc.

Have you had an accident or trauma to the spine?

It is important to know what types of injuries you have had. This includes lifting injuries, car accidents, etc.

Have you noticed difficulties with your bowel or bladder?

This question is very important since spine specialists want to be able to exclude the possibility that you have a spinal cord or a severe spinal nerve problem. When the spinal cord or the cauda equina are compressed it may affect your ability to empty your bladder or bowels.

What makes your pain better or worse?

List what you do to help yourself as well as what you avoid.

Do you have weakness in your arms or legs?

This is an important question because true weakness may mean a nerve in the spine is very compressed. This may signal a more severe problem, which sometimes requires surgery within a short period of time to avoid a chronic nerve injury.

Have you ever had medical care for this problem?

Here it is important to let the spine specialist know if you have seen other doctors for this. Perhaps you have been given a diagnosis, had certain tests, or were given a specific treatment for the problem. If you have seen other spine specialists, it is important to bring organized records. It is very important for the spine specialist to see the prior data, which may include consultations with other doctors, reports of images, reports of surgery, medications tried, etc.

Are you taking any medications for this problem?

It is very important for the spine specialist to know what medication and how often you are taking it. For instance, some medications are blood thinners which may make it dangerous to have an injection or surgery.

Have you had injections or surgery of the spine in the past?

It is critically important to list all that you know of, or at least write where and when you had something done even if you do not know exactly what it was. The spine specialist’s office can often track down the records for you.

Some spine specialists may also have you fill out specific questionnaires such as the Oswestry Disability Index (ODI), or Neck Disability Index (NDI), Beck Depression Inventory. These standardized questionnaires can give a score which helps the spine specialists assess the severity of your symptoms and allows them to track your progress over time. These tests are also often used for formal patient studies.

 

B. Spine Examination

When a spine specialist examines you, they perform certain observations and tests to evaluate the kind and severity of a spine problem. It can be useful to know about these tests so you have some idea what the doctor is evaluating.

Here are some of the common examinations:

  1. Spine Inspection

A spine inspection is often the first step for a doctor to examine your spine. The patient should remove their clothes so the spine can be seen directly. As patients remove their clothes, the doctor can see how much motion they have or if they are avoiding certain types of movements due to pain or spasm.

A spine inspection usually starts by looking for unusual areas on the patient’s skin. There are some markings on the skin which can point to a neurological problem. Even some birth marks are associated with spinal conditions. Also, some lumps or bumps under the skin can be seen just on a visual inspection.

The spine is also inspected for a symmetrical appearance of the anatomy on either side of the spine. The hips and pelvis should be level. A scoliosis or a spine curved abnormally due to severe spasms can often be seen.

      2. Spine Palpation

The next step in examining the spine is called palpation, which means evaluating through touch. It can be done by sitting on a stool behind a standing patient. A good place to start is to find the tops of our hip bone (iliac crest) and trace a line horizontally across the back. This line often intersects at the level of the L4 vertebrae. From there the doctor can count the vertebrae up and down the spine.

The spinous processes (tips of bone which you feel under the skin in the middle of your spine) are then felt. Missing spinous processes can point to a condition called ‘spina bifida’ which is a condition from birth where the bones in the middle part of the spine did not come together completely.

If one of the spinous processes sticks out more than others (step-off), there may be a slip between the vertebrae, called a spondylolisthesis. In the neck (cervical spine), the C-7 spinous process is always more prominent, which helps the doctor count levels of vertebrae and discs.

After palpating the bone parts of the spine, the softer tissues such as the muscles and ligaments can be evaluated. The ligaments on top of the spinous processes (supraspinous ligaments) can often be felt under the skin. If they are very tender to touch, there may be an inflammation or in the case of trauma, a disruption of the ligament.

The muscles of the spine can also be evaluated directly. If the patient arches slightly backwards, the muscles tend to be more relaxed and easier to evaluate. Tenderness and spasm of the muscles can be evaluated. Also, the conditioning of the muscles can be felt. Certain muscles can be isolated during an exam, perhaps pointing to a specific diagnosis.

The sciatic nerve (combination of lumbar and sacral nerves, running within one large nerve bundle) can be located in an area called the sciatic notch, an area between the pelvis and the thigh bone. Patients with sciatica will often be uncomfortable when pushing in the area of the nerve.

Palpation can be very important in understanding and locating a patient’s pain and knowing approximately which segment of the spine this corresponds to.

      3. Spine Range of Motion

Range of motion in the spine can offer important clues about the status of discs, ligaments, facet joints and muscles of the spine. Areas of the spine where the discs are tallest and the joints are largest, usually have more motion. Often motion at one particular spinal segment can be compared to others to find an area of disease.

Range of motion is examined in particular directions (planes): Flexion (forward bending), extension (backward bending), side-bending, and rotation

      4. Adams Forward Bent Test

This test looks for the presence of an abnormal spinal curvature (scoliosis).The patient is asked to bend forward with the knees together, legs straight, and arms dangling. The doctor looks at the spine and rib cage to see if one side is higher than another, which could be due to a scoliosis.

      5. Leg Length Measurement

Measuring the length of each leg can give important clues about causes of spine pain. The length of each leg is often measure with the patient lying on their back (supine). The doctor makes sure the pelvis is level. The doctor places a hand on each ankle, feeling for the bone in the inside of the ankle (medial malleolus). A discrepancy between them can point to one leg being longer than the other. This does not mean that the actual leg is truly longer, but that part of the spine, hip or pelvis is causing it to appear that way.

      6. Spine Facet Loading Maneuver

The facet joints in the spine move during forward (flexion) and backward bending (extension). When bent backward while leaning off to one side, the patient is “loading the facet joint”. This means, that a maximum amount of pressure is placed on the joint. Spine specialists will have patients do this maneuver to see if they have pain. The pain felt during this maneuver is thought to come from inflamed facet joints.

      7. Spine Neurological Examination

The neurological examination of the spine is the key to understanding if a patient has a potentially dangerous neurological problem as part of their spine disease.

Since the spine sends nerves to our arms and legs, a lack of strength, sensation or an absence of a reflex can indicate nerve compression in the spine. Often the neurological exam will point to a specific nerve (s), which can confirm the diagnosis.

Some neurological problems, such as severe compression of the spinal cord can be found on an exam and will alert the doctor to make a rapid diagnosis and the potential need for urgent surgery.

Here are some of the common neurological tests performed:

a. Cervical Spine (Neck)

Since degeneration of the discs happens most frequently between the C-5 and C-7 vertebrae, the neurological examination of these levels is presented below.

       C-5:

  1. C-5: Muscle tested: Deltoid muscle

Test: the doctor has the patient lift the elbow upward at 90 degrees to the shoulder; this is done by first placing your elbow against the side of your chest and then lifting it straight outward; the doctor pushes downward on the elbow to test the deltoid muscle.

      2. Reflex tested: Biceps reflex

Test: the doctor strikes the tendon of the biceps at the elbow with a reflex hammer. The response is measured.

      3. Sensation tested:

Test: the skin over the upper inside area of the upper arm is tested by touch or with a sharp object.

          C-6:

  1. C-6 Muscle tested: Biceps muscle

Test: the doctor has the patient lift the forearm at the elbow (like doing a curl with a weight) while resisting the motion at the forearm by pushing downward.

      2. Reflex tested: Brachoradialis reflex

Test: the doctor strikes the brachioradialis tendon located close to the wrist on top of the forearm, with a reflex hammer. The response is measured.

      3. Sensation tested:

Test: The skin over the upper inner aspect of the forearm is tested by touch or with a sharp object.

 

            C-7:

  1. Muscle tested: Triceps muscle

Test: the doctor has the patient lift the arm with the elbow bent at 90 degrees; the patient then tries to straighten the arm while the doctor resists.

      2. Reflex tested: Triceps reflex

Test: the doctor strikes the triceps tendon, located above the elbow on the back of the arm, with a reflex hammer. The response is measured.

     3. Sensation tested:

Test: the doctor tests the skin over the middle finger on the palm side of the hand either by touch or with a sharp object.

 

b. Lumbar Spine (Back)

Since degeneration of the discs happens most frequently between L-4 and S-1 vertebrae, the neurological examination of these areas is presented below.

 

       L-4:

  1. Muscle tested: Tibialis Anertior

Test: the doctor places a hand on the top of your foot, close to the first mid-foot bone (metatarsal) and resists you while you try to tilt the foot upwards at the ankle.

      2. Reflex tested: Patellar Reflex

Test: The doctor strikes the ligament just below the kneecap with a reflex hammer. The response is measured.

      3. Sensation tested:

Test: the skin is tested by touch or with a sharp object on the inside of the lower leg and ankle.

          L-5:

  1. Muscle tested: Extensor Hallucis Longus (L-5)

Test: the doctor places one finger on the big toe and resists you while you try to lift the toe upward.

  1. Reflex tested: The L-5 Nerve does not have a reflex
  2. Sensation tested:

Test: the skin is tested by touch or with a sharp object over the outside of the lower leg and top of the foot.

             S-1:

  1. Muscle tested: Peroneus Longus and Brevis

Test: the doctor has the patient push downward at the ankle while resisting the foot at the sole; another test is to secure the patient’s ankle while the patient tries to ‘airplane’ (tilt) the ankle outward.

      2. Reflex tested: Achilles Reflex

Test: the doctor strikes the back of achilles tendon with the reflex hammer while lifting the ankle to the neutral position (90 degrees). The response is measured.

      3. Sensation tested:

The skin is tested by touch or with a sharp object on the outside of the foot and the sole of the foot.

 

Spine Special Tests

These tests are done to get specific detailed information about the spine. The human body has specific responses to certain maneuvers the doctor performs. The responses to these maneuvers can tell the doctor if a disease is present.

A. Cervical Spine

  1. Distraction test

This test is done to see if nerve pain to the arm is relieved when lifting the head straight upward by placing one hand under the chin and one hand at the back of the head.

If a nerve is compressed by a herniated disc, for instance, lifting the segment may relieve the pressure on the nerve and subsequently the pain.

      2. Compression test

The compression test is the opposite of the distraction test. The neck is compressed by pushing downward on the top of the head. If a nerve is compressed by a disc herniation, for instance, then the pain would worsen with the compression of the segment.

      3. Valsalva test

The Valsalva test is done with the patient holding his/her breathe and then bearing down as if they are having a bowel movement. If the spinal cord or spinal nerve is compressed, the increase in pressure generated by the maneuver, can cause symptoms such as pain, numbness or weakness in the arms or legs.

      4. Spurling’s Sign

This test is done to diagnose a compressed nerve in the neck. The physician has the patient bend the neck backwards, then rotated to the side where the pain is typically located. Following that, the patient’s head is pushed straight downward. If the patient experiences pain in the arm, then the test is positive for a compressed nerve in the spine.

      5. Hoffman’s Sign

A Hoffman’s sign is a test to evaluate the presence of spinal cord compression. The test is done in the hands. With the fingers slightly flexed, the tip of the middle finger is flicked upward (extension) or downward (flexion). If the other fingers of the hand respond by bending downward (flexion), the test is considered positive.

      6. Lhermitt’s Sign

A Lhermitt’s sign is a test done to see if the spinal cord is compressed in the neck. The patient bends the neck forward (flexion) while standing. The presence of an electrical sensation running down the back and into the arms and legs could indicate that the spinal cord is compressed in the neck.

      7. Ankle Clonus test

In this test, the doctor lifts the foot upward at the ankle in quick, jerking type movements. If the foot flutters up and down by itself following this maneuver a problem may be present in the spinal cord or brain.

      8. Babinski test

A sharp object is run across the sole of the foot from the heel to outside of the sole and then to the balls of our foot, and then back across to the inside. In a positive test, the big toe pulls upward, while the other toes do not. This can indicate a neurological problem in the brain or spinal cord.

      9. Kernig’s Sign

The Kernig’s sign is a test for an infection of the brain, spinal cord, or spinal fluid. The patient is placed on the back (supine). The thigh is bent to 90 degrees at the hip and knee. When the patient’s neck is bend forward (flexed), the patient cannot straighten the legs due to severe tightness in the hamstring muscles.

      10. Rectal Examination

The rectal examination is often important in patients with a suspected neurological injury to the spinal cord or cauda equine.

The rectal sphincter is examined for strength. A lack of sphincter strength and control can confirm a neurological injury.

      11. Gait Testing

Gait testing is another important test to evaluate the neurological status of a patient. Often the normal gait is assessed for signs of instability. A “tandem gait” is the assessment of a patient who walks heel-to-toe. Instability of the gait can point towards spinal cord or spinal nerve compression.

 

B. Lumbar Spine

  1. Straight Leg Raising test (Lasegue’s Sign)

This test evaluates the patient for the presence of sciatica or nerve inflammation. The patient is lying on the back (supine) and one leg at a time is raised while the doctor supports the leg at the heel. The leg is raised slowly, keeping the knee straight, until pain develops in the leg and calf. The doctor notes the point at which the pain occurred and measures the angle between that point and the table (e.g. the patient developed pain in the leg when the leg was lifted 45 degrees off the table).

Pain that occurs in this fashion can be due to sciatica. The test can be verified by lowering the leg slightly after the patient experiences pain and then pulling the foot upward at the ankle. If that maneuver causes the same pain again, then the presence of sciatica is more likely.

      2. Pelvic Rock test

The patient is positioned flat on their back (supine). The doctor pushes the front of the pelvis inward which spreads out the sacroiliac joints (joints between the tailbone and the pelvis) in the back of the pelvis. If a patient has a problem with the sacroiliac joint, pain may occur during this maneuver.

      3. Gaenslen’s test

The patient lies on their back with one leg dropped off the side of the table and the other leg flexed at the knee joint. Pain that occurs in the area of the sacroiliac joint may indicate inflammation of the joint.

      4. Patrick test

This test is done to evaluate the patient for a hip or sacroiliac joint problem. The patient is positioned on the back (supine). One leg at a time is first bent at the waist (hip flexion), then rotated outward and finally leaned outward. The heel of that foot is placed on the shin of the opposite leg. Pain that occurs in the groin and hip area may be due to a hip problem such as arthritis. Pain that occurs over the sacroiliac joint may be due to a problem in that joint.