Spine examination in detail orthopedic surgeon

Reading File

Finding Sources

Reading File

Finding Sources

Reading File

Finding Sources

Reading File

Finding Sources

Reading File

Finding Sources

Loading Image

I now have all the content needed for a comprehensive, well-illustrated answer. Here is the full spine examination guide:

Spine Examination - Comprehensive Orthopedic Guide

Sources: Bailey and Love's Short Practice of Surgery 28th Ed.; Rockwood and Green's Fractures in Adults 10th Ed. 2025; Textbook of Family Medicine 9th Ed.

Anatomy Overview

The spinal column consists of 33 vertebrae with 23 intervertebral discs, supported by numerous ligaments and paraspinal muscles. The spine has four physiological sagittal curves:

Cervical lordosis (20-40°)
Thoracic kyphosis (20-45°)
Lumbar lordosis (40-60°)
Sacral kyphosis

General Inspection (Standing Patient)

Coronal Plane (from front and back)

The head should be centered over the sacrum
A plumb line dropped from the spinous process of C7 should fall through the gluteal crease
If it falls to either side, lateral tilt is present
The ear, shoulder, and greater trochanter should lie in the same vertical plane

Figure: Plumb line used to assess coronal alignment

Sagittal Plane (from the side)

Assess all four physiological curves
Loss of lumbar lordosis suggests muscle spasm or ankylosing spondylitis
Increased thoracic kyphosis (Scheuermann's, osteoporosis, Pott's disease)

1. CERVICAL SPINE EXAMINATION

Look

Expose the shoulders, back muscles, and scapulae
Look for: muscle wasting, asymmetry of neck creases, shoulder-level inequality
Check for normal cervical lordosis (20-40°)

Feel

Stand behind the patient, support the patient's chin.

Soft tissues: Feel for spasm of paraspinal muscles
Bone: Palpate spinous processes for tenderness and alignment; C7 (vertebra prominens) and T1 are easily palpable at the base of the neck

Move - Range of Motion

Motion occurs in three planes:

Movement	Normal Range	Technique
Flexion	45°	Chin to chest; measure chin-sternum distance
Extension	55°	Look up at the ceiling
Right/Left Rotation	70° each	Look over each shoulder without moving the chest
Right/Left Lateral Bending	40° each	Lay ear on ipsilateral shoulder

Neurological Assessment (C5-T1 nerve roots)

Root	Dermatome	Key Muscle	Reflex
C5	Lateral arm (regimental badge area)	Deltoid / Biceps	Biceps (C5/C6)
C6	Lateral forearm, thumb, index finger	Wrist extensors / Biceps	Brachioradialis
C7	Middle finger	Triceps / Wrist flexors	Triceps
C8	Medial forearm, ring/little finger	Finger flexors / Intrinsics	-
T1	Medial arm	Intrinsic hand muscles	-

Special Tests - Cervical Spine

Spurling's Test (for cervical nerve root entrapment) The examiner extends the patient's neck, rotates and side-bends the head toward the affected side, and applies downward axial compression. A positive test reproduces radicular arm pain. Low sensitivity, high specificity.

Spurling's test for cervical radiculopathy

Figure: Spurling's test - neck extended, rotated toward affected side with downward compression

Cervical Distraction Test Patient supine. Examiner places one hand under the chin, another on the occiput, and gently applies traction. Positive: improvement in radicular symptoms. Tests for nerve root compression. Low sensitivity, high specificity.

Upper Limb Tension Test (ULTT) Patient supine. Examiner depresses the scapula, then places the shoulder in abduction, extends the elbow and wrist, and side-bends the neck contralaterally. Positive: reproduction of radicular symptoms. Sensitivity >90%, low specificity.

2. THORACIC SPINE EXAMINATION

The thoracic spine is normally convex with a gentle kyphosis (20-45°). Pathology commonly presents as pain and deformity.

Look

Expose from neck to gluteal cleft, front and back.

Skin: Cafe-au-lait spots, hairy patches (suggesting occult neural/bony pathology), scars
Front: Asymmetry of shoulder and ribcage (scoliosis)
Back: Difference in iliac crest height (pelvic tilt); coronal plane deformity (scoliosis = lateral curvature with rotation); rib hump
Side: Sagittal deformity (increased kyphosis)

Feel

Palpate with one hand supporting the patient's pelvis.

Paraspinal muscles for spasm
Spinous processes for tenderness, step-off

Move

Forward Bending Test (Adam's Test) Ask the patient to bend forward and touch their toes:

Structural scoliosis: Rib hump increases (bulges posteriorly on the thoracic convex side) as the patient bends - diagnostic of idiopathic thoracic scoliosis (rotatory deformity)
Functional scoliosis: Spine straightens and no rib hump is visible; flexible deformity secondary to leg-length discrepancy or lumbar muscle spasm

Lateral Bending: Used to assess the flexibility of scoliosis; radiographs can be taken in this position.

3. LUMBAR SPINE EXAMINATION

Always include assessment of pelvis, hips, lower limbs, gait, and peripheral vascular system. Irritation of lumbar nerve roots can mimic lower limb problems. Always consider referred pain.

Look

Back: Check for hairy tufts and dimples at the base of the spine (underlying spina bifida occulta); unilateral paraspinal muscle prominence (spasm secondary to pain)
Side: Normal lumbar lordosis (40-60°); muscle spasm causes loss of lordosis

Feel

Palpate spinous processes for any step-off - this may indicate forward slippage (spondylolisthesis)
Paraspinal muscle tenderness

Move - Range of Motion

Movement	Normal Range	Technique
Forward flexion	Variable (Schober's)	Fingertips toward floor; measure lumbar skin stretch using Schober's test
Extension	~25-30°	Lean backwards
Lateral bending	~25° each	Hand slides down outside of thigh
Rotation	3-18°	Hold pelvis fixed; patient twists and looks over shoulder

Schober's Test (Modified): Place thumb tip over the T12/L1 junction and index finger over L5/S1. As the patient bends forward, the distance between these points should increase by at least 5 cm in normal lumbar flexion. A smaller increase suggests restricted lumbar mobility (ankylosing spondylitis, etc.)

Neurological Assessment (L1-S1 nerve roots)

Root	Dermatome	Key Muscle (Power Test)	Reflex
L1/L2	Groin/upper inner thigh	Hip flexors (psoas)	Cremaster
L3	Inner/anterior thigh	Quadriceps (knee extension)	Knee jerk
L4	Medial shin/foot	Tibialis anterior (ankle dorsiflexion)	Knee jerk
L5	Lateral shin, dorsum of foot, great toe	Extensor hallucis longus (great toe extension)	Absent
S1	Lateral foot, sole	Gastrocnemius (ankle plantarflexion)	Ankle jerk
S2-S4	Perineum/perianal	Bladder/bowel/sexual function	Bulbocavernosus/anal reflex

Note: Always assess perianal sensation and voluntary anal contraction when cauda equina is suspected.

4. SPECIAL TESTS FOR THE LUMBAR SPINE

Lasègue's Straight Leg Raise (SLR) Test

Tests tension along the sciatic nerve (L5 and S1 nerve roots)

Technique (three-step method):

With patient supine, elevate the leg with the knee bent - checks pain-free hip movement
Straighten the knee - note the angle at which hamstrings allow hip flexion
Allow hip to extend until hamstring tension is removed, then firmly dorsiflex the ankle - this pulls on the sciatic nerve

Positive test: Pain radiating down the leg (not just the back) between 30-70°.

Sensitivity: >80% (for disc herniation)
Specificity: ~40%

Figure: Straight leg raise (Lasègue's test) - step (a) initial lift with knee flexed

Crossed (Contralateral) SLR Test

Elevate the asymptomatic leg; if pain is reproduced in the opposite (symptomatic) leg, this is positive.

High specificity (~90%) for large central disc herniation

Femoral Stretch Test (Reverse SLR)

Patient prone. Flex the knee to 90°, then extend the hip. Positive test (pain in anterior thigh/groin) suggests upper lumbar (L2, L3, L4) nerve root involvement.

FABER Test (Patrick's Test)

Flexion, Abduction, External Rotation of the hip - helps differentiate hip pathology from sacroiliac joint pathology.

FADIR Test

Flexion, Adduction, Internal Rotation - screens for hip impingement and hip pathology.

5. GAIT ASSESSMENT

Observe walking from front, side, and behind:

Antalgic gait: Shortened stance phase on the painful side
Trendelenburg gait: Contralateral pelvis drops (L5 root or gluteus medius weakness)
Steppage gait: High-stepping to clear foot drop (L4/L5 root palsy)
Spastic gait: Broad-based with circumduction (upper motor neuron lesion - myelopathy)
Heel walk: Tests L4/L5 (dorsiflexors)
Toe walk: Tests S1 (plantarflexors)

6. NEUROLOGICAL EXAMINATION - COMPLETE CORD/CAUDA EQUINA ASSESSMENT

For trauma or suspected cord injury, use the ASIA Impairment Scale (American Spinal Injury Association):

ASIA Grade	Type	Description
A	Complete	No motor or sensory function preserved in sacral segments S4-S5
B	Incomplete	Sensory preserved below injury level, no motor function
C	Incomplete	Motor preserved below level; most key muscles grade <3
D	Incomplete	Motor preserved below level; most key muscles grade ≥3
E	Intact	Normal motor and sensory function

MRC Motor Grading Scale:

Grade	Description
0	No contraction
1	Flicker/trace of contraction
2	Movement with gravity eliminated
3	Movement against gravity
4	Movement against some resistance
5	Normal power

Upper Motor Neuron vs Lower Motor Neuron Signs:

Sign	UMN (myelopathy)	LMN (radiculopathy)
Tone	Increased (spastic)	Decreased (flaccid)
Reflexes	Hyperreflexia	Hyporeflexia/absent
Plantars	Extensor (Babinski)	Flexor
Wasting	Minimal	Present
Clonus	Present	Absent

7. RED FLAGS - REQUIRING URGENT INVESTIGATION

Red Flag	Concern
Fever, weight loss	Infection, malignancy
Saddle anesthesia, bowel/bladder incontinence or retention	Cauda equina syndrome
Recent trauma	Fracture/instability
History of cancer	Metastatic disease
Night pain unrelieved by rest	Malignancy
History of IV drug use	Discitis/osteomyelitis
Immune suppression / chronic steroids	Infection, fracture
Progressive neurological deficit	Compressive lesion

8. CLINICAL EXAMINATION SEQUENCE SUMMARY

Standing patient:

Coronal inspection (plumb line, scoliosis, pelvic tilt)
Sagittal inspection (kyphosis, lordosis)
Gait assessment (heel walk, toe walk, tandem)

Palpation: 4. Spinous processes (tenderness, step-off, crepitus) 5. Paraspinal muscles (spasm) 6. Sacroiliac joints, sciatic notch

Range of motion: 7. All planes for the affected spinal region (record in degrees)

Neurological: 8. Sensation (light touch, pinprick in dermatomes) 9. Power (key muscle groups by myotome) 10. Reflexes (biceps, brachioradialis, triceps, knee jerk, ankle jerk) 11. Plantar response (Babinski) 12. Clonus (ankle/patella)

Special tests: 13. SLR / Crossed SLR (lumbar) 14. Spurling's / Distraction test (cervical) 15. FABER/FADIR (hip differentiation) 16. Forward bending / Adam's test (thoracic scoliosis)

Supine / Prone: 17. Abdominal reflexes 18. Femoral stretch test 19. Perianal sensation and anal tone (if cauda equina suspected)

Bailey and Love's Short Practice of Surgery, 28th Ed., pp. 497-500 | Rockwood and Green's Fractures in Adults, 10th Ed. 2025, pp. 2117-2118 | Textbook of Family Medicine, 9th Ed., pp. 848-849

This is a shared conversation. Sign in to Orris to start your own chat.