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The vertebral column = spine

the central supporting structure

of the trunk and back

Shape and posture
- Unusually thin or obese?
- Overall posture?
- Spine straight or unusually curved?
- Shoulders level?
- Limbs normally positioned?
- Deformities?
- Swelling or wasting?
- Lump?

Wasting Gibbus
- Colour : reflects vascular status, pigmentation

Pallor ;ischaemia Blueness ;cyanosis Redness ;inflammation

- Markings of skin

- Scars

- Bruise/wounds/ulcerations

- Abnormal creases : fibrosis, underlying deformity

- Tight, shiny skin, no creases : typical for oedema

Skin : warm/cold? moist/dry? sensation?
Soft tissues : lump? characteristics? pulses normal?
Bones and joints : outlines normal?
Tenderness : patients face?
- Try to localize any tenderness to a particular structure
Vertebral landmarks
Active movement
Passive mobility
Abnormal or unstable movement
Provocative movement
ASIA (American Spinal Injury Association)

Standard method of assessing the neurological status of a

person who has sustained a spinal cord injury
Strength assessment of 10 muscles on each side of the body
Light, touch and pin-prick discrimination assessment at 28
specific sensory locations on each side.
Steps in classification
1. Sensory level for right and left side

2. Motor level of the right and left side

3. Neurological level of injury (NLI)

4. Whether the injury is complete or incomplete

5. ASIA Impairment scale (AIS) Grade (A/B/C/D/E)

Sensory Level
The sensory levels are scored on a 0 to 2 scale for each dermatome
If body is divided into two identical halves there are 28 key sensory
points to be tested.
Each dermatome is tested for light touch and pinprick sensations and
labeled as NT (not testable) if cannot be tested.
Otherwise, following scores are given to each sensory point
0 The sensation is absent
1 The sensation is present but impaired
2 The sensation is normal
Scores are individually tested for both light touch and pin prick are
normal. A maximum possible score is 112 points for each of them for a
patient with normal sensation.
In addition presence or absence of anal sensation is noted.
Motor Level
10 key muscles = 5 in the upper limb + 5 in the lower limb
5-point muscle grading scale

The sum of all 20 muscle yields a total motor score for each
patient, with a maximum possible score of 100 points for
patients with no weakness
(no weakness = 100 points)
Level of Neurological Impairment
Injury is complete if there is :
- No voluntary anal contraction
- S4-5 sensory scores = 0
- Anal sensation = No
Otherwise injury is incomplete
Level of Neurological Impairment
The ASIA neurological impairment scale is based on the Frankel classification of spinal cord
A = Complete No motor or sensory function is preserved in the sacral
segments S4-S5

B = Incomplete Sensory but no motor function is preserved below the

neurological level and includes the sacral segments S4-S5

C = Incomplete Motor function is preserved below the neurological level, and

more than half of key muscles below the neurological level have
a muscle grade of less than 3

D = Incomplete Motor function is preserved below the neurological level, and at

least half of the key muscles below the neurological level have
a muscle grade of 3 or more

E = Normal Motor and sensory function are normal.

Neurological examination
Tendon reflexes
Superficial reflexes
The plantar reflexes
Tendon reflexes
Monosynaptic segmental reflex the reflex pathway takes a
short cut through the spinal cord at the segmental level
Upper limb: biceps, triceps, brachioradilais
Lower limb: patellar, achilles tendons
Tendon reflexes

Patellar jerk (L1,2,3,4 roots) Achilles jerk (S1,2 roots)

Superficial reflexes
By stroking the skin at various sites to produce a specific
muscle contraction
Abdominal (T7-T12)

Cremasteric (L1,2)

Anal (S4,5)

Absence of the reflexes indicates an UMN lesion

Superficial reflexes

Location of Normal Abnormal

Reflex Stimulus
lesion response response
Stroking the abdomen diagonally from
T7-T12 Contraction of No contraction
upper and lower quadrants toward
Abdominal rectus abdominis

Upward motion of No motion of

Stroking the medial thigh proximal to
Cremasteric T12- L1 the scrotum the scrotum
Plantar reflexes
Location Normal Abnormal
Reflex Stimulus
of lesion response response

Upper Stroking the plantar aspect of

Babinski motor foot proximal lateral to distal
neuron medial Toe
Rubbing the tibial crest proximal hyperflex
Oppenheim motor
to distal
Spurlings test

Cervical nerve root

compression causing cervical
Patient seated and sidebends
to affected side
Apply downward compression
on the head of the pt
Positive: When the pain arising
in the neck radiates in the
direction of the corresponding
dermatome ipsilaterally
Cervical Compression test
Press down upon the top of
pts head
If there is increase pain in
either cervical spine or upper
extremity, note its exact
distribution. Locate the
neurological level
A narrowing of neural
foramen, pressure on the facet
joints or muscle spasm can
cause increase upon
Distraction test
To relieve pressure on
cervical nerve roots.
Place the open palm of one
hand under the pts chin and
the other hand is upon
Slowly traction the patients
head in a superior direction,
maintain for 30 seconds.
Spurlings test : superior to the distraction test in that it would
be more specific to the exact side or portion of the cervical
spine that is affected
Cervical compression test: equal to the cervical distraction test
as it is testing for the same tissues, but instead of relieving
pain, the movement reproduces pain
Valsalva test
Ask pt to hold breath and bear down as if he
were moving his bowels
This test increase intrathecal pressure
Positive Finding:
Increased spinal or radicular pain due to
intrathecal pressure
May be secondary to a space-occupying
lesion (i.e. herniated disc, tumor,
Straight Leg Raising Test
SLR along with relevant history and decreased range of motion,
are considered by some to be the most important physical
signs of disc herniation, regardless of the degree of disc injury
SLR is a neural tension test that can be used to rule in or out
neural tissue involvement as a result of a space occupying
lesion, often a lumbar disc herniation
To evaluate lumbar nerve root (L4-S1) impingement/irritation
(lumbosacral radiculopathy) and sciatic neuropathy
SLR is a passive test.
Each leg is tested individually with the normal leg being tested
When performing the SLR test, the patient is positioned in
supine without a pillow under his/her head
The hip medially rotated and adducted, and the knee
The clinician lifts the patient's leg by the posterior ankle while
keeping the knee in a fully extended position and continues to
lift the patient's leg by flexing at the hip until the patient
complains of pain or tightness in the back or back of the leg
between 30-70 : lumbar disc herniation
at the L4-S1 nerve roots.
less than 30 : acute spondyloithesis,
gluteal abscess, disc protrusion or
extrusion, tumor of the buttock, acute
dural inflammation, a malingering
patient, or the sign of the buttock.
greater than 70 degrees : tightness of
the hamstrings, gluteus maximus, or
hip capsule, or pathology of the hip or
sacroiliac joints
After the elicitation of symptoms, the examiner can slowly and
carefully lower the leg until the patient no longer feels pain or
Next, either the patient is asked to bring his or her chin to the
chest, or the examiner may dorsiflex the patient's foot, or both
actions may be done simultaneously; however, foot dorsiflexion
is most commonly performed first. Both maneuvers are
considered to be provocative or sensitizing tests for
neurological tissue.
Pain that increases with neck flexion or foot dorsiflexion or
both indicates stretching of the dura mater of the spinal cord
or a lesion within the spinal cord (e.g. disc herniation, tumor, or
Pain that does not increase with neck flexion may indicate a
lesion in the hamstring area (tight hamstrings) or in the
lumbosacral or sacro-iliac joint
Inclusion of neck flexion in the SLR is documented
as Brudzinski's Sign
Inclusion of ankle dorsiflexion in the SLR is documented
as Bragard's test
Inclusion of great toe extension in the SLR (instead of ankle
dorsiflexion) is documented as Sicard's Test
Femoral Nerve Traction Test

Used to stress the femoral nerve and the mid lumbar (L2-L4) nerve
The examiner extends the knee while extending the hip
approximately 15. The knee is then flexed to further stretch the
femoral nerve.
The patients back must be straight and not hyperextended.
Positive: if pain radiates down the anterior thigh.
Bowstring Test
Cram test/popliteal pressure test
Test position:
Patient supine
Examiner performs a passive straight leg raise on involved side
If subjects reports radiating pain, examiner flexes the subjects knee to
approximately 200 in attempt to reduce pain
Pressure then applied to popliteal area to reproduce radicular pain
Positive finding:
Painful radicular reproduction with popliteal compression
Indicates sciatic nerve tension
Bowstring test
Waddells sign

To identify psychogenic, or non organic,

manifestations of pain in patients that may
have heightened emotional effects on their
3 of the 5 signs should be present
Waddells sign
Superficial and Widespread tenderness or Nonanatomic tenderness
- Skin discomfort on light palpation or tenderness crossing over non-anatomical boundaries
Stimulation tests Axial loading and Pain on simulated rotation

- eliciting pain when pressing down on the top of the patients head or rotating the
shoulders and pelvis together should not be painful
Distracted straight leg raise

- if a patient complains of pain on straight leg raise, but not if the examiner extends the
knee with the patient seated at another time during the initial evaluation
Non-anatomic sensory changes: Regional sensory changes and regional weakness

- sensory loss in an entire extremity or side of the body or weakness that is non consistent
and jerky, ie "cogwheeling"

- Exaggerated painful response to a stimulus, that is not reproduced when the same
stimulus is given later