The neurological examination meets orthopedic medicine in the spine. Most patients with back or neck pain have musculoskeletal causes, and most do not need neurological evaluation. But a substantial minority have radiculopathy, myelopathy, or peripheral nerve compression as the dominant problem, and the bedside distinction between an orthopedic problem and a neurologic one rests on a focused set of provocative maneuvers and pattern recognition. The neurologist who can perform a competent neuro-orthopedic exam often makes diagnoses that the general examiner misses, particularly when the pain pattern is misleading or when motor and sensory findings have been overlooked.

This page covers the bedside exam at the interface of neurology and orthopedics: the provocative tests for radiculopathy, the signs of myelopathy, the maneuvers that elicit nerve entrapment, and the patterns that distinguish neurologic from purely mechanical pain. The point is to give the trainee a focused set of tools for the patient with neck or back pain whose history suggests possible neurologic involvement.

Cervical Spine and Brachial Plexus

Cervical Radiculopathy

Cervical radiculopathy presents with neck and arm pain often in a dermatomal distribution, with associated weakness in the muscles supplied by the root and reflex changes. The most common levels are C6, C7, and C5. Bedside features by level:

Spurling Maneuver

The Spurling maneuver is the classical provocative test for cervical radiculopathy. The examiner extends the patient’s neck, rotates and laterally flexes it toward the symptomatic side, and applies gentle axial compression downward on the top of the head. The maneuver narrows the neural foramen on the affected side, and reproduction of radicular arm pain or paresthesia is a positive test.

Specificity is high but sensitivity is moderate; a negative Spurling does not exclude radiculopathy. The test should not be performed in patients with significant cervical instability, fracture, or rheumatoid involvement of the upper cervical spine, in whom compression could cause neurological injury.

Lhermitte Sign

An electric shock-like sensation traveling down the spine, often into the limbs, produced by flexing the patient’s neck. The phenomenon reflects mechanical stimulation of demyelinated fibers in the cervical cord — most often multiple sclerosis, but also from cord compression, B12 deficiency, and tabes dorsalis. Lhermitte sign is one of the more pathognomonic bedside findings in neurology when present, although it is not specific to MS.

Cervical Myelopathy

Cervical myelopathy is compression of the spinal cord at the cervical level, most often from spondylosis (degenerative disc and facet disease with osteophyte formation) but also from acute disc herniation, ossification of the posterior longitudinal ligament (especially in Asian populations), tumor, and other causes. The bedside picture combines features of cord disease with often subtle motor and sensory findings:

• Gait disturbance: spastic gait with a wide base, sometimes with the patient describing “feet feeling clumsy” or difficulty walking on uneven surfaces.
• Hand clumsiness (“myelopathy hand”): difficulty with fine motor tasks (buttoning, writing). The patient often complains of clumsiness or dropping objects.
• Hyperreflexia below the level of compression: brisk reflexes in the legs are typical. Reflexes at the level of compression may be reduced (where the root is involved) and reflexes above the level are normal.
• The combination of “wasted arms and spastic legs”: cervical roots compressed at the level of myelopathy produce lower motor neuron findings in the arms (wasting, weakness, reduced reflexes) while corticospinal tract compression produces upper motor neuron findings in the legs (spasticity, hyperreflexia, extensor plantars). This is the classical presentation.
• Babinski sign and other extensor plantar responses.
• Hoffmann sign: see Pyramidal Signs Catalog.
• Lhermitte sign on neck flexion.
• Sensory level on the trunk in some patients.
• Bladder dysfunction: urgency, frequency, or retention.

The cardinal “soft signs” of early cervical myelopathy — subtle hand clumsiness, slight gait broadening, faintly brisk reflexes — are easily missed without specific examination. Any older patient with vague hand clumsiness and a gait that has lost some of its rhythm deserves a careful cervical exam and consideration of imaging.

Thoracic Spine

Thoracic myelopathy or radiculopathy is less common than cervical or lumbar, and the symptoms are often vague. A sensory level on the trunk, sometimes with radicular pain wrapping around the chest or abdomen, and bilateral leg weakness (often spastic) are the cardinal findings. The neurologic exam must establish the level by carefully testing pinprick from below upward until the level of preserved sensation is identified.

Causes include disc herniation (uncommon at this level), tumor (vertebral metastasis, intramedullary tumor), epidural abscess, and inflammatory lesions such as transverse myelitis.

Lumbosacral Spine

Lumbosacral Radiculopathy

The L5 and S1 radiculopathies are by far the most common, typically from disc herniation. L4 is less common but important. The bedside picture:

Straight Leg Raise (Lasègue Sign)

The classical provocative test for L5 or S1 radiculopathy. The patient lies supine. The examiner lifts the affected leg, keeping the knee extended, until either the patient reports pain in the leg (not just back pain) or the leg reaches about 70-90 degrees. A positive test reproduces radicular pain shooting down the leg, typically before 60 degrees, often in the L5 or S1 distribution. Pure back pain without radiation is not a positive test.

Sensitivity is reasonable (around 80%) but specificity is poor. Cross-straight leg raise — radicular pain in the affected leg produced by raising the contralateral (unaffected) leg — is much more specific for disc herniation but less sensitive.

Femoral Stretch Test (Reverse Lasègue)

For higher lumbar radiculopathies (L2, L3, L4). The patient lies prone or on the unaffected side; the examiner flexes the knee while extending the hip. A positive test reproduces anterior thigh pain, typical for upper lumbar root irritation.

Cauda Equina Syndrome

Compression of the multiple lumbar and sacral nerve roots within the spinal canal produces a recognizable syndrome that is a surgical emergency. Cardinal features:

• Bilateral leg weakness, often asymmetric, in multiple root distributions.
• Severe radicular pain in the legs, often bilateral.
• Saddle anesthesia: loss of pinprick sensation in the perianal area and the inner thighs. Test this in every patient with bilateral leg pain and any urinary symptoms.
• Urinary retention or incontinence: overflow incontinence (urinating because the bladder is overfull and dribbling) is more sensitive than complete urinary retention as an early sign. Reduced anal tone on rectal exam confirms the diagnosis.
• Absent or reduced lower extremity reflexes: the lesion is at the root level (lower motor neuron), so reflexes are reduced rather than brisk.

The most common cause is acute large disc herniation, often with previous chronic back pain in the same area. Other causes: tumor, epidural abscess, traumatic injury, lumbar stenosis with acute decompensation. Imaging is urgent (MRI of the lumbar spine), and surgical decompression within 48 hours is associated with substantially better recovery of bowel and bladder function.

Conus Medullaris Syndrome

A lesion of the conus medullaris (the tapering end of the spinal cord, at the L1-L2 vertebral level) produces a distinctive picture: bilateral saddle anesthesia, prominent early urinary and bowel dysfunction, less prominent leg weakness than cauda equina, and (because the lesion is at the cord) sometimes both upper and lower motor neuron features. The differential and management are similar to cauda equina.

Neurogenic Claudication

Lumbar spinal stenosis produces a characteristic pattern: leg pain or numbness brought on by walking and standing, relieved by sitting, leaning forward, or lying down. The pattern is sometimes called “shopping cart sign” because patients can walk normally if they can lean forward over a cart. The differential includes vascular claudication (peripheral arterial disease), distinguished by:

Piriformis Syndrome

Compression of the sciatic nerve by the piriformis muscle produces sciatic-distribution pain (buttock to posterior leg), worsened by sitting on hard surfaces and by certain hip movements. Tenderness over the piriformis muscle on rectal exam can be a clue. The diagnosis is often clinical and somewhat controversial; treatment is conservative (physical therapy, anti-inflammatories, occasionally injections).

Provocative Tests for Specific Conditions

FABER (Flexion, Abduction, External Rotation) Test

The patient lies supine, and the examiner places the affected leg in the figure-4 position (ankle resting on the opposite knee). Downward pressure is applied to the knee and the opposite ASIS. Pain reproduces sacroiliac joint pathology or hip pathology (the latter producing more anterior groin pain). Useful in distinguishing radiculopathy from sacroiliac or hip joint pain.

Slump Test

The patient sits upright on the edge of a table. They flex the neck (chin to chest), slump the trunk forward, and extend the knee while dorsiflexing the foot. The maneuver tensions the entire neural axis from the brain to the foot. Reproduction of radicular leg pain is a positive test, sometimes more sensitive than the straight leg raise.

Tests for Sacroiliac Joint Dysfunction

Several maneuvers — FABER, Gaenslen test, distraction test, compression test, sacral thrust — stress the sacroiliac joint and reproduce pain in SI joint dysfunction. The cumulative finding of three or more positive tests is reasonably specific for SI joint pathology.

The Approach to Back Pain with Neurologic Concern

Most back pain is musculoskeletal and self-limited. The features that mandate neurologic evaluation:

• Radicular pain: shooting pain in a dermatomal distribution, with or without weakness or sensory loss.
• Weakness in a root or nerve distribution.
• Sensory loss in a root or nerve distribution.
• Bowel or bladder symptoms: urinary retention, urgency, or incontinence; fecal incontinence. These mandate emergency evaluation for cauda equina or conus medullaris syndrome.
• Saddle anesthesia: must be tested specifically in any patient with bilateral leg symptoms or any urinary complaints.
• Progressive weakness: motor deficits worsening over days or weeks.
• Constitutional symptoms: fever, weight loss, night pain — raise the possibility of infection, tumor, or inflammatory disease.
• Recent trauma: even minor in patients with osteoporosis or known malignancy.
• Pain in older patients with cancer history: epidural metastatic disease.
• Severe nocturnal pain: often suggests inflammatory or neoplastic causes rather than mechanical disease.

Imaging Considerations

MRI of the relevant spinal segment is the test of choice for any patient with significant neurologic findings or “red flag” features. Plain radiographs are useful for trauma and for assessing alignment; CT is useful for bony detail and in patients who cannot undergo MRI. Always image the spinal segment that corresponds to the clinical findings — a patient with cervical myelopathy needs MRI of the cervical cord, not the lumbar spine.

🔍 Did You Know?

Saddle anesthesia is the most consistent neurological finding in cauda equina syndrome, but it is the most often missed bedside finding in neurology — partly because examiners are reluctant to test perianal sensation, and partly because patients with bladder symptoms often do not report numbness in this area unless specifically asked. The clinical rule: always test perianal pinprick in any patient with new urinary symptoms and back or leg pain. A few seconds of bedside examination can identify a surgical emergency that imaging may not be ordered for if the diagnosis is not considered.

Pitfalls and Pearls

• The Spurling maneuver is specific for cervical radiculopathy. A positive test reproducing arm pain or paresthesia is helpful; a negative test does not exclude the diagnosis.
• Lhermitte sign is more specific than it is sensitive. When present, it points to cord disease — most often MS, but also myelopathy, B12 deficiency, and other dorsal column pathology.
• Cervical myelopathy is the most underdiagnosed cause of mild gait disturbance in older patients. Wasted arms with spastic legs is the classical pattern; subtle hand clumsiness with brisk leg reflexes is the early picture.
• The straight leg raise should reproduce leg pain, not just back pain, to be considered positive.
• Cross-straight leg raise is more specific than ipsilateral straight leg raise. When positive (raising the unaffected leg reproduces pain on the affected side), it strongly suggests disc herniation.
• Saddle anesthesia is an emergency finding. Always test perianal sensation in patients with bilateral leg pain or urinary symptoms.
• Cauda equina syndrome requires urgent imaging and surgical evaluation. Decompression within 48 hours improves recovery of bowel and bladder function.
• L5 radiculopathy vs peroneal palsy: L5 weakens gluteus medius (hip abduction) and tibialis posterior (inversion); peroneal palsy spares both. Test these specifically.
• Neurogenic claudication improves with flexion (sitting, leaning forward, walking uphill); vascular claudication does not.
• “Red flag” features mandate imaging: progressive neurologic deficit, bowel or bladder dysfunction, saddle anesthesia, severe night pain, history of cancer, constitutional symptoms, trauma. Routine back pain does not require imaging in the absence of these.
• The myelopathic patient with brisk knee jerks and normal-appearing ankle jerks may show this because lumbar stenosis is also present (the level is mixed). Always consider that more than one level may be involved in older patients.

References

1. Campbell WW. DeJong’s The Neurologic Examination. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2013. Chapters 47-48.
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4. Tarulli AW, Raynor EM. Lumbosacral radiculopathy. Neurol Clin. 2007;25(2):387-405.
5. Suri P, Hunter DJ, Boyko EJ, et al. Physical examination findings predict lumbar disc herniation. Spine J. 2010;10(8):649-654.
6. Tetreault L, Goldstein CL, Arnold P, et al. Degenerative cervical myelopathy: a spectrum of related disorders affecting the aging spine. Neurosurgery. 2015;77(Suppl 4):S51-67.
7. Katz JN, Harris MB. Lumbar spinal stenosis. N Engl J Med. 2008;358(8):818-825.