Summary of Key Points
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The history and physical examination is of the utmost importance in determining the correct diagnosis and appropriate surgical plan in patients being evaluated for a spinal disorder.
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The physical examination should focus on the following:
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Generalized inspection of the patient, emphasizing cutaneous features, posture, and gait analysis
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Inspection and palpation of the entire spinal column, with range of motion (ROM) testing of both the spine and joints of affected extremities
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Sensory and motor evaluation
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An assessment of normal and pathologic reflexes
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Provocative nerve root testing as indicated
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Joint pain is frequently misdiagnosed as radicular pain and needs to be ruled out before surgical intervention is instituted.
Advances in medical technologies and changes in health care systems have dramatically altered the practice of medicine and the physician-patient relationship. One consequence of these changes, unfortunately, is that the physical examination is no longer the focus of many physician-patient encounters and is often overlooked when important clinical decisions are made. In the field of spine surgery, the widespread availability of neuroimaging of the spinal column and modern health care policies regulating coverage of elective surgery are two factors that have contributed to this change. Patients who are often referred for their initial consultation with their magnetic resonance imaging (MRI) “in hand” worry more about the radiologist’s interpretation of the scan than their symptoms. In many instances, patients are required to consult with multiple surgeons and receive conflicting recommendations regarding the appropriateness of surgical treatment. In this environment, it is essential for the surgeon to place a priority on the fundamentals of history taking and the neurologic examination to establish good rapport with patients and guide them in choosing the best therapy.
History Taking
A surgeon’s ability to efficiently obtain a thorough history is the cornerstone of treating patients with spinal disorders. The foundation of good history taking lies in being a good listener. Communicating a genuine interest in the patient and a willingness to offer both surgical and nonsurgical treatment are of paramount importance. This is true in both straightforward and complicated patients (such as those suffering from chronic pain syndromes). By using simple, open-ended questions early in the interview, the physician allows patients to articulate their perception of the problem, which helps the physician to identify treatment goals. The physician can then ask a patient more focused questions to obtain the necessary information to formulate a preliminary differential diagnosis. For example, asking the patient to point to the area of maximum pain and to trace the pattern of the pain or paresthesia often yields valuable diagnostic information.
Careful review of the patient’s past medical history is important to uncover conditions with symptoms commonly seen in patients with spinal pathology. Diabetes, peripheral vascular disease, inflammatory arthropathies, and neoplastic disorders are common examples. Any history of trauma involving the spine and related surgical procedures should be noted, in addition to injuries involving the shoulder, hip, and long bones. Unrecognized compression neuropathies secondary to casting, for example, can subsequently be confused with radiculopathy. Retroperitoneal hematoma may present as a femoral or an upper lumbar radiculopathy. It is also important to inquire about a history of any psychiatric disorders and pain syndromes associated with joints, muscles, or connective tissues. Fibromyalgia and reflex sympathetic dystrophy can alter perioperative pain management and may require additional attention. Inquiry about smoking history is also important because smoking has been demonstrated to increase the incidence of pseudarthrosis compared with nonsmoking.
Taking a good history regarding pain associated with spinal disorders deserves special attention. Radicular pain tends to be constant but may be exacerbated by movement or Valsalva maneuvers. The pain occurs in the distribution of the affected nerve root and may have dysesthetic qualities. Mechanical back pain resulting from degenerative disc disease, spondylotic changes of the facets, or gross instability from trauma or cancer tends to be worse with movement and relieved with rest. The pain associated with neurogenic pseudoclaudication is typically an aching or cramping pain in the buttocks, thighs, or legs that becomes worse with standing and walking short distances and is relieved with bending, sitting, or reclining. Pain or paresthesia in the hands that awakens the patient at night and is relieved by shaking the hand is a red flag for nerve entrapment. Pain or paresthesia radiating to the upper extremities that is associated with medial scapular pain is more likely to be radicular in origin.
It is noteworthy that not all patients in neurosurgical consultation have neurologic disease processes. Other etiologies mimicking neurologic syndromes must be considered.
General Physical Examination
Although a comprehensive general physical examination may not be feasible in every patient, details gathered from the patient’s medical history serve as a guide to performing an examination of other organ systems. Basic vital signs should be recorded in most patients. Hypertension and atrial fibrillation are two examples of disorders easily identified by physical examination that could significantly affect diagnosis and operative risk in a patient with transient cerebral ischemia. Auscultation of the lungs and palpation of the abdomen are essential in the setting of metastatic spine disease. Emphysema, chronic obstructive pulmonary disease, pleural effusion, extensive atelectasis, and ascites have an impact on anesthetic risk and may influence patient positioning and surgical approach. Gallbladder disease may refer pain to the back or scapula and may be mistaken for cervical radiculopathy. Nephrolithiasis or ureterolithiasis is often mistaken for a lumbar radiculopathy and may be screened for by gentle percussion over the lumbar paraspinal musculature. Examination of peripheral pulses and distal skin integrity is important in patients with diabetes and possible vascular claudication.
Components of the Neurologic Examination
After completing the relevant portions of the general examination, the neurologic examination is performed. The surgeon may choose to focus the examination on a particular spinal region, but patients often complain of symptoms referable to both the cervical and thoracolumbar spine, particularly those with extensive spondylosis. A comprehensive examination may also be beneficial, for example, by uncovering signs of cervical myelopathy in a patient who needs lumbar decompression and may be at risk for neurologic deterioration during positioning or intubation. Evaluation of cranial nerve function should be included in patients with bulbar symptoms or with coexisting head and spinal trauma. A comprehensive examination should include (1) generalized inspection of the patient, emphasizing cutaneous features, posture, and gait analysis; (2) inspection and palpation of the entire spinal column, with range of motion (ROM) testing of both the spine and joints of affected extremities; (3) sensory and motor evaluation; (4) an assessment of normal and pathologic reflexes; and (5) provocative nerve root testing if previous examination has raised the suspicion of radiculopathy. The order in which these modalities are tested is dictated by surgeon preference, but minimizing patient movement and reserving maneuvers that may cause pain for the end of the examination are important considerations.
Inspection
A generalized inspection of the patient with emphasis on cutaneous features, posture, and gait is carried out when the patient first appears for evaluation and the history is reviewed.
Cutaneous Abnormalities
The skin should be inspected for café au lait spots and other sequelae of neurofibromatosis, in addition to scars from old trauma or prior surgery. The dorsal midline skin should be carefully inspected for a sinus tract, dimpling, abnormal pigmentation, fatty masses, and tufts of hair, all of which could signal an underlying congenital spinal anomaly. In patients with symptoms of claudication, the peripheral pulses are palpated and the skin of the distal extremities is inspected for edema, skin ulceration, loss of hair, and other signs of peripheral vascular disease.
Posture
Inspection of the spinal column as a single unit should be performed from both a lateral and posterior viewpoint in standing and forward bending positions. Abnormalities in spinal balance in both the sagittal and coronal planes can be pathologic and have important implications when considering surgical deformity correction. Asymmetry of paravertebral muscles, spinous processes, skin creases, shoulders, scapulae, and hips may be appreciated in patients with scoliosis. Coronal imbalance can be assessed clinically by examining the standing patient from behind and measuring the distance between a plumb line dropped from C7 and the gluteal cleft. Sagittal imbalance may be implied when a patient stoops forward when walking or sitting. It is best determined by a plumb line from C7 to the sacrum on lateral radiographs. A compensatory forward rocking of the pelvis and flexion of the knees while standing may be seen in severe cases. The recognition of sagittal imbalance is paramount to precise surgical planning, especially when planning for deformity correction.
Gait Analysis
Examination of a patient’s gait is an invaluable component of the neurologic examination. Watching patients walk as they appear for consultation, even before formal testing begins, can be of diagnostic value.
Alterations of Gait Associated with Cord Compression.
A wide-based, unsteady gait is frequently seen in myelopathic patients and can be accentuated by evaluating tandem walk. Unfortunately, a wide-based gait is not specific for myelopathy and is common in patients with cerebellar pathology, decreased proprioception resulting from peripheral neuropathy, and conditions affecting posterior column function, such as tabes dorsalis, vitamin B 12 deficiency, and spinocerebellar ataxias. A spastic gait can be seen in patients with stroke or in those with an old cord injury and is manifested by circumduction of a hemiplegic leg or “scissoring” of the legs in a paraparetic patient. The diagnosis of Parkinson’s disease should always be kept in mind when patients referred for possible myelopathy display a shuffling gait (festination) with either forward (propulsion) or backward (retropulsion) walking.
Other Characteristic Gaits.
Patients suffering from compression of neural elements of the lumbosacral spine often show characteristics of antalgic gait. This term is somewhat nonspecific but involves alteration of the movement of the affected extremity in an attempt to silence the pain generator. Lumbar radiculopathy associated with weakness of several different muscles can alter gait. Weakness of ankle dorsiflexors and foot drop may cause a patient to walk with a “steppage gait.” To clear the ground while the patient pushes off, the hip is flexed excessively and the foot may slap the ground. Weakness of gluteus medius (L5) hip abduction or gluteus maximus (S1) hip extension may cause the patient to rock the thorax, or “waddle,” to compensate for poor hip fixation. Patients with advanced lumbar stenosis and neurogenic claudication tend to walk in a flexed-forward position, commonly referred to as the “anthropoid posture.” The spinal surgeon should keep psychiatric disorders on his or her list of differential diagnoses when assessing gait. Gait and posture disturbances are the presenting symptom in up to 10% of patients with psychogenic disorders such as anxiety and depression.
Palpation and Range of Motion Testing of the Spine and Related Areas
Formal palpation and ROM testing of the spinal column, shoulders, hips, and pelvis are also included in a comprehensive examination. The spinous processes of the entire vertebral column are palpated and assessed for tenderness and associated paravertebral muscle spasm. Splaying of adjacent spinous processes or a palpable step-off may indicate spondylolisthesis. Patients with fibromyalgia and related disorders frequently complain of pain exacerbated by stimulation of multiple trigger points. Axial rotation, flexion, extension, and lateral bending are assessed for each region of the spine.
Cervical Spine
In the cervical spine, the resting head position is noted before evaluation of ROM. A patient with a fixed rotation or tilt to one side may have an underlying unilateral facet dislocation. Although precise quantitative evaluation of ROM is not typically performed, the clinician should note obvious limitations and which maneuvers generate pain. Pain or restricted rotation of the head, 50% of which occurs at C1-2, may indicate a pathologic process at this level. Head rotation associated with vertigo, tinnitus, visual alterations, or facial pain may be nonspecific, but occlusion of the vertebral artery should be included in the differential. Selecki showed that rotation of the head more than 45 degrees could significantly kink the contralateral vertebral artery. Extension and rotation of the head can exacerbate preexisting nerve root compression, and flexion in the setting of cord compression often causes paresthesia in both the arms and legs ( Lhermitte sign ).
Thoracic Spine
Examination of the thoracic spine should focus on the detection of scoliosis or a kyphotic deformity. The patient is observed from behind for symmetry in the level of the shoulders, scapulae, and hips. If a scoliotic deformity is noticed on inspection, flexion and lateral bending are assessed to further characterize the curve and determine its flexibility. Asymmetry in the paravertebral musculature with forward flexion can generate an angle in the horizontal plane that can be followed for progression.
Lumbar Spine and Related Areas
Palpation should include not only the spinous processes and paravertebral muscles but the greater trochanter, the ischial tuberosity, and the sciatic nerve itself. The greater trochanter is palpated for focal tenderness when the patient’s chief complaint includes thigh discomfort. The bursa is usually not palpable unless it is boggy and inflamed. Acute trochanteric bursitis is included in the primary differential diagnosis of lumbar radiculopathy and can also be a chronic secondary pain generator. The sciatic nerve can be palpated at the midpoint between the greater trochanter and ischial tuberosity when the patient’s hip is maximally flexed. Tenderness can occur with peripheral nerve compression by a tumor or an enlarged piriformis muscle or when the contributing roots are compressed in the spine.
The most important aspect of ROM testing in the lumbar spine is flexion-extension. A simple clinical test is to ask the patient to bend forward with the knees fully extended, and measure the distance from the patient’s fingertips to the floor. Patients with facet arthropathy or spondylolisthesis often have back pain that is exacerbated by extension. Lateral bending and axial rotation are strongly coupled in the lumbar spine and more restricted because of sagittal facet orientation. It is critical to exclude the hip as a potential pain generator in the evaluation of possible lumbar spine disease. The Patrick or FABERE test is used to detect pathology in the hip or sacroiliac (SI) joint. The patient is tested in the supine position, and the extremity in question is flexed, abducted, and externally rotated at the hip. This can be accomplished by asking the patient to place the lateral aspect of the foot on the involved side on the opposite shin. Pain with this maneuver is likely from the hip joint. Pain from the SI joint itself is suspected when simultaneous downward pressure on the flexed knee and the opposite anterior superior iliac spine increases symptoms. The SI joint can also be tested as a pain generator by performing the pelvic rock test . The examiner places both hands around the iliac crest with the thumbs on the anterior superior iliac spine and compresses medially.
Motor Examination
Muscle weakness is frequently seen in patients suffering from compression of specific nerve roots or the spinal cord itself. Weakness may be the patient’s primary symptom or discovered only after physical examination. Motor deficits may be acute and rapidly progressive (i.e., after traumatic disc herniation) or more insidious in onset, similar to the setting of cervical myelopathy. A detailed motor examination and muscle grading ( Table 12-1 ) of the key muscles innervated by the cervical and lumbar nerve roots should be performed in every patient. Evaluating strength systematically allows the clinician to identify common patterns of muscle weakness seen in cord compression and brachial plexus syndromes and reduces the likelihood of missing nonsurgical pathology.
| Grade | Description |
|---|---|
| 0 | No palpable/visible contraction |
| 1 | Muscle flicker |
| 2 | Movement with gravity eliminated |
| 3 | Movement against gravity with full range of motion |
| 4 | Movement against gravity and some resistance |
| 5 | Movement against full resistance |
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