Neurologic Assessment

Spinal Neurological Assessment (Spot Knowledge)

General Principles

• Includes motor, sensory, and reflex exam of all extremities

• Use Manual Muscle Testing (0–5 scale) for consistency

• Reflexes graded as: 0 = absent, 1+ = diminished, 2+ = normal, 3+ = brisk, 4+ = clonus

Upper Extremity

Motor

• C5 – Shoulder abduction (deltoid), elbow flexion (biceps)

• C6 – Elbow flexion, wrist extension

• C7 – Elbow extension (triceps), wrist flexion

• C8 – Finger flexion

• T1 – Finger abduction (intrinsic muscles)
  💡 Grip (C8) and finger abduction (T1) often early affected in cervical radiculopathy

Sensory

• C5 – Lateral shoulder

• C6 – Radial forearm, thumb

• C7 – Middle finger

• C8 – Little finger, ulnar hand

• T1 – Medial forearm

Reflexes

• C5–C6: Biceps → elbow flexion

• C6: Brachioradialis → elbow flexion, forearm supination

• C7: Triceps → elbow extension

Special Tests

• Spurling: axial load with neck extension/lat. flexion → radicular pain = positive

• Lhermitte: electric-shock sensation with neck flexion → cervical myelopathy

• Hoffman: flicking distal phalanx of middle finger → thumb flexion/adduction = UMN sign

Lower Extremity

Motor

• L2 – Hip flexion

• L3 – Knee extension

• L4 – Ankle dorsiflexion

• L5 – Great toe extension (EHL)

• S1 – Plantar flexion, eversion

• S2 – Knee flexion
  💡 L5 weakness → cannot heel walk; S1 weakness → cannot toe walk

Sensory

• L2 – Anterior thigh

• L3 – Knee region

• L4 – Medial leg/ankle

• L5 – Dorsum of foot, great toe

• S1 – Lateral foot, little toe

• S2 – Posterior thigh

Reflexes

• L4: Patellar (quadriceps)

• S1: Achilles (gastrosoleus)

• Pathological:

  • Babinski – great toe dorsiflexion = UMN sign

  • Clonus – rhythmic ankle beats with forced dorsiflexion = UMN sign

  • Chaddock/Oppenheim – Babinski equivalents

Special Tests

• SLR (Lasègue): 30–70° → radicular pain = L4–S1 compression

• Bragard: pain reappears with ankle dorsiflexion after SLR

• Cross Lasègue: contralateral leg raising provokes pain → severe root compression

• Femoral Nerve Stretch: prone, knee flexion → anterior thigh pain = L2–L4 compression

Clinical Pearls

• Always check sacral segments (S4–S5) → anal tone, perianal sensation, bulbocavernosus reflex

• Document systematically (ASIA/ISCoS standards if possible)

• Radiculopathy → loss of reflex in affected root

• Myelopathy → hyperreflexia + pathological reflexes

References

1. American Spinal Injury Association (ASIA). International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). 2022.

2. Hoppenfeld S, DeBoer P. Examination of the Spine and Extremities. Appleton & Lange, 1976.

3. Fehlings MG, Tetreault LA, et al. Assessment of spinal cord injury and myelopathy. Lancet Neurol. 2017;16(6):482–492.

4. Dumitru D, Amato AA, Zwarts MJ. Electrodiagnostic Medicine. 2nd ed. Hanley & Belfus, 2002.

5. Kendall FP, et al. Muscles: Testing and Function with Posture and Pain. 6th ed. Lippincott Williams & Wilkins, 2020.