Mark S. Greenberg and Daniel Marin

I. Key Points

– There are four main components to the spinal exam: motor, sensory, reflex, and mechanical. This is in addition to the general exam, which includes observation for cutaneous and nail changes, deformity, pain behaviors, and other signs.

– Although components of a general survey nature should always be included, the physical exam is tailored to specific situations based on the history, the region of suspected involvement, and abnormal findings during the survey exam.

– No protocol can cover every contingency, and the exam must be individualized based on patient-specific factors. The order of the exam procedures must also be tailored to the situation.

II. Main Components of the Spinal-Related Exam

– Motor (strength, coordination, spasticity, muscle bulk/tone including atrophy/fasciculations)

Abbreviation: ROM, range of motion.

– Reflexes (muscle stretch reflexes, pathologic reflexes, cutaneous reflexes, sacral reflexes, and priapism)

*In the lower extremities, reinforcement consists of having the patient hook the tips of the fingers of the left hand into the tips of the hooked fingers of the right hand and pulling (Jendrassik maneuver). Reinforcement in the upper extremities consists of having the patient clench the teeth.

• Further reflex testing, as indicated, includes abdominal cutaneous reflexes, anal wink, and bulbocavernosus.

• Priapism may indicate spinal cord injury.

– Mechanical factors (including observation for cutaneous changes, pain behaviors, muscle bulk/tone, and provocative maneuvers)

• Gait and station. Casual gait is assessed in all patients to check balance, weakness that compromises gait, and pain manifestations. Tandem gait and/or the Romberg test can further assess balance and posterior-column (proprioceptive) function.

• Cervical spine

Cervical range of motion and specific levels of tenderness should be documented to distinguish myofascial from bone-related factors. Specific facet pain diagram patterns can be reviewed with the patient to identify problem levels.

The Spurling maneuver (axial loading on the vertex of the head with rotation to one side, repeated with rotation to the other side) may reproduce cervical nerve root symptoms in a patient with herniated cervical disc or foraminal stenosis.

Shoulder pathology can often mimic cervical spine pathology. Tenderness of the acromioclavicular joint to palpation or a positive empty-can test suggests primary shoulder pathology as a cause of shoulder pain.

• Lumbar spine

Lumbar range of motion and specific levels of tenderness should be documented to distinguish myofascial from bone problems.

*A reflex that is not widely used and may be difficult to elicit.

Laségue sign or straight-leg raising (SLR). Supine patient raises one lower extremity (LE) at a time. Classically positive findings include pain or paresthesias in the distribution of the involved nerve root (not just back pain) at less than 60 degrees elevation. In response the patient may lift the hip on the involved side off the exam table. This procedure helps to differentiate radiculopathy from hip pathology (e.g., trochanteric bursitis). Positive in 83% of cases with nerve root compression, it is more sensitive for compression in L5 or S1 than in upper lumbar roots.

Femoral stretch test or reverse straight-leg raising. With patient prone, the knee is flexed on one side at a time. This test is more likely to be positive than SLR with upper lumbar nerve root compression (L2, L3, or L4).

• Hip and sacral pain. It is important to distinguish hip-mediated pathology and low back pathology.

Palpation over spinous processes, paraspinal muscles, greater trochanters (to assess for greater trochanteric bursitis), and SI joints (Fortin finger test) may suggest sacroiliitis.

FABER (acronym for flexion, abduction, external rotation, also called the Patrick test) test of the hip with the patient supine: back pain suggests musculoskeletal lower back or sacroiliac pain; groin or hip pain suggests hip pathology.

Shear test can help distinguish sacral pain. Patient prone, the examiner applies pressure to the sacrum while applying a traction force caudad with the corresponding limb. A test is positive if it reproduces the patient’s typical pain.

• Vascular considerations: Palpation for pedal pulses to rule out vascular insufficiency.

III. Clinical Pearls

– Babinski sign or a positive Hoffmann sign: if there is no known etiology in a given patient, further investigation is required (to rule out cord compression or brain involvement).

– Cervical radiculopathy does not cause pain with shoulder abduction.

– Painless weakness in the LE is almost never due to lumbar nerve root compression. Consider diabetic neuropathy, cervical spondylotic myelopathy, or motor neuron disease, for example.