STATIC PALPATION OF THE SPINEDaniel Redwood, D.C. Kevin R. Mott, D.C. . INTRODUCTION Static palpation of the human spine is an art and a learned skill of examination, via superficial touch, of the vertebral column, which is comprised of the spine, sacrum and coccyx. Used primarily as a diagnostic aid or tool, static palpation is concerned with tactile perception of various osseous landmarks, involving the following: (1) locating specific vertebral structures, (2) becoming aware of the particular structure’s characteristics; and (3) assessing the particular structure’s current state or condition. Static palpation of the human spine is just one component of the diagnostic process and does not stand alone as all encompassing – there are limitations. Static palpation must, therefore, be followed by further assessment measures, including kinetic palpation, orthopedic testing, and x-ray analysis. The practice of static palpation involves multiple positions for both the examiner and examinee. Within the chiropractic profession, the most common position for the Doctor of Chiropractic to assume is a fencer stance parallel to the chiropractic table. With the patient lying in the prone position upon the table, the doctor uses his or her finger tips or pads, locating and assessing all parts of the vertebral column. As an alternative method, the patient may assume the seated position with the doctor standing to either side or directly behind the patient. The doctor may then proceed to palpate in a fashion similar to the previous patient position. This alternate doctor-patient position proves most useful for occiput and cervical spine palpation. OCCIPUT AND CERVICAL SPINE The cervical spine has seven (7) vertebrae, including the atypical vertebrae of the upper cervical complex, comprised of the atlas (C1) and the axis (C2), and the typical vertebrae C3 through C5. C6 and C7 are additionally classified as atypical cervical spine vertebral segments because they are transitioning to take on characteristics of the thoracic spine. and (7) triangular-shaped neural (spinal) foramen. an analogous posterior tubercle exists on the posterior arch. the posterior cranial bone that lies superior to the atlas and articulates with it. There is neither a vertebral body nor a spinous process. however. (5) bilateral transverse foramina within each transverse process. use the pads of your index (2nd) and chiropractic index (3rd) fingers to palpate the posterior midline of the cranium just above the base of the occiput. being similar in this way to the spinous processes of the thoracic and lumbar vertebrae. which is also characteristic of thoracic-spine transverse processes. (3) three cervical “lips” on the vertebral body – 2 uncinate (lateral) processes and 1 anterior-inferior process. the transverse processes of C7 project more laterally than anteriorly. the EOP palpates as a clearly defined bump.Functionally the upper cervical spine also includes the occiput. Palpation: Standing to the side of your seated patient. The atlas (C1) is atypical because it is ring-shaped. (2) bifid spinous process.or oval-shaped vertebral body. Another unique attribute of C2 is its odontoid process (dens). at the midpoint of the superior nuchal line. and two lateral masses. (4) bilateral transverse processes located anterior to the superior articular processes. It is helpful to use the EOP as a starting point in locating key structures in the upper cervical spine. The axis (C2) is atypical because it does not possess the two uncinate (lateral) processes. C6 and C7 are atypical cervical vertebral segments because they both lack a bifid spinous process. Moreover. (6) bilateral costotransverse grooves on each transverse process. The normal cervical spine displays a lordotic curve. External Occipital Protuberance (EOP) – the EOP (also known as the inion. On most people. displaying an anterior and posterior arches. or bump of knowledge) is located on the midline of the occiput. with the convexity of the curve to the anterior as seen from a side (lateral) view. . The typical cervical vertebra (best exemplified by C3-C5) is characterized by the following structural characteristics: (1) rectangular. Due to its delicate structure. palpate in the groove between the inferior mastoid tip and the jaw. Styloid Process – located on the temporal bone. Transverse Process of Atlas (C1) – the atlas transverse is located slightly inferior and slightly anterior to the inferior tip of the mastoid process. it feels similar to the rubber eraser on a pencil. Then. the styloid is never used as the contact point for an adjustive thrust. moving the overlying sternocleidomastoid muscle. . the styloid will be very sensitive to the patient. which is just posterior to the jaw. Palpation: Using a small palpating surface such as a single finger tip. it is not readily palpable on many people. On palpation. the styloid process lies immediately posterior to the jaw and immediately anterior to the inferior tip of the mastoid process. Palpation: Sitting or standing posterior to your seated patient. This is the mastoid process. the mastoid process is located just behind the pinna of the ear. Because the styloid is small and slender (often compared to the lead of a pencil point). start with your chiropractic index fingers on the inferior tips of the right and left mastoid processes. dome-shaped structure. until you find the TVP. slide them gently downward behind the ear until you feel a curved. slide your palpating fingers of both hands laterally from the EOP until they are even with the most posterior aspect of the external ear. you may need to move your palpating fingers in small circles. If accessed. To precisely locate the atlas TVP. Palpation: Standing or sitting behind your patient. Continue palpating downward until you reach the inferior tip of the mastoid. To palpate the atlas transverse process. It projects further laterally than any other structure in the cervical spine. using the pads of your chiropractic index fingers. palpate the structure bilaterally.Mastoid Process – located on the temporal bone. move slightly inferiorly and slightly anteriorly. Do not go so far to the anterior that you reach the styloid. Posterior Tubercle of Atlas – the posterior arch of atlas spans the distance between the posterior tubercle and the transverse process of the C1 vertebra. Spinous processes from C2-C5 are bifid. or 2-2½” below the EOP. The C6 spinous is noteworthy for being the lowest freely moving spinous process in flexion and extension of the cervical spine. and is not usually palpable except on some thin-necked patients. and palpate inferiorly from the prominent C2 spinous. Palpation: With the patient seated and the doctor standing at the patient’s side. which is the longest of the cervical spinous processes. Palpation: Stand at the side of the patient (as with C2). as described above. It is large and relatively wide and is the largest of the cervical spinouses in thickness and mass.Posterior Arch of Atlas. This division is sometimes palpable. . Spinous Process of Axis (C2) – the C2 spinous process is the first palpable spinous below the EOP. is located at the posterior midline. move inferiorly to the groove just below the base of the occiput. The posterior tubercle is analogous to the spinous processes of all other vertebrae. judging the approximate location of the C3-C5 spinous processes and identifying them specifically when possible. but usually it is not. due to their relatively small size and the fact that they are tucked forward as part of the lordotic curve of the cervical spine. which is the C2 spinous. The posterior arch of atlas is analogous to the lamina of all other vertebrae. Spinous Processes of C6-C7 – these spinous processes project more prominently to the posterior than the C3-C5 spinouses. This is particularly pronounced with C7. Spinous Processes of C3-C5 – the spinous processes of the mid-cervical vertebrae are difficult to palpate specifically. Palpate the posterior arch of atlas. It lies approximately ½” below the depression that lies just beneath the base of the occiput. palpate with the pad of your index finger in an inferior direction from the EOP until you reach the first clearly palpable midline structure. divided into two attached sections as they near the tip. Palpation of posterior arch: from the EOP. Then find the transverse process of C1. which links these two structures. then they are likely to be C7 and T1 and you will need to move both fingers up one level and repeat the above process to confirm the location of C6. The above procedure may also be accomplished with the patient lying in the prone position. or with a combination of the two.Palpation: To determine which of the lower cervical spinouses is C6. The above procedure may be accomplished with the patient either seated or lying in the prone position. Articular Pillars – the articular pillars occur only in the cervical spine between C2-C7. which is on the posterior midline. placing your thumb on the side of the patient closest to you (ipsilateral) and your chiropractic index finger on the side away from you (contralateral). If the . Vertebra Prominens (VP) – the vertebra prominens (Latin: most prominent vertebra) is the vertebra near the cervico-thoracic junction that projects the farthest to the posterior. Standing at the side of your seated patient. by finding the most inferior movable spinous process in the cervical spine (C6). If the superior of the two contacted spinouses moves away from your palpating index finger while the inferior one remains stationary. unlike the softer tissue that surrounds it. They are comprised of the superior and inferior articular processes of these vertebrae. by palpation. bony structure. then the upper one is C6 and the lower is C7. If both remain stationary. and your 2nd (true index) finger on the spinous above that. To be able to accurately identify the exact levels of the individual thoracic vertebrae. You may need to move your palpating fingers laterally or medially from the starting point in order to locate the articular pillar. The key point is that the articular pillar will palpate as a hard. which together form a stacked (though also curved) column. Palpation: Follow the directions above for identifying the spinous processes of C6 and C7. begin to palpate at approximately the midpoint between the most posterior and most lateral points at that level. place your 3rd (chiropractic index) finger on what you expect to be the C7 spinous. find the spinous process of the vertebra. Palpation: To locate the articular pillar at a particular level of the cervical spine. it is important to determine whether the VP is C7 (as it is in most cases) or T1. Then find the most lateral aspect of the neck at that level. It can be located visually. Gently extend the patient’s neck. the thoracic spine demonstrates a kyphotic curve. Continue this process all the way to the T12 spinous process. Another approach is to use the pads of your thumbs as the doctor’s contact point. Because each of the thoracic vertebrae connects to the right and left ribs. the VP is C7. Locating the spinous process is necessary before one can locate its corresponding transverse process. . The upper thoracic vertebrae (T1-4) share characteristics with the lower cervicals (long spinous processes projecting posteriorly and slightly inferiorly). and then rising up again as you reach the T2 spinous process. with no imbrication present at T11 and T12. THORACIC SPINE The thoracic region is the longest section of the spine. The middle thoracics (T5-8) provide the best examples of the typical thoracic vertebra. each with four vertebrae. vertebral movement is limited. which decreases the likelihood of losing your place as you count downward through the thoracic spinous processes. particularly in flexion and extension. as described above) or counting upward from L4 (described below). dipping down into the T1-T2 interspinous space just below it. palpation in the seated position may also be practiced. The lowest thoracic vertebrae show characteristics of the nearby lumbar vertebrae (thick spinous processes projecting posteriorly). This results in significantly overlap of the midthoracic spinous processes . If it lays two levels below the movable C6 spinous. however. slide downward from T1. You may also alternate thumbs. known as imbrication. Thoracic spinous process palpation is best accomplished with the patient lying in the prone position. with long spinous processes that angle sharply downward. Thoracic Spinous Processes – correctly identifying the level of a thoracic spinous process requires either counting downward from T1 (identified in relation to C6 and C7.VP lies immediately below the movable C6 spinous. The thoracic spine is divided into three zones. In normal circumstances. accounting for 12 of the spine’s 24 vertebrae. with the convexity of the curve to the posterior as seen from a side (lateral) view. The lower thoracics (T9-T12) demonstrate progressively less imbrication. it is T1. Palpation: using the tip or pad of your index or chiropractic index finger. first locate the T1 spinous process as described above. you have correctly identified the location transverse process. count down to the desired spinous process. If the spinous process of the more inferior vertebra (under your more inferiorly placed thumb) moves in response to movement of the transverse process. Keep it there while palpating superiorly with your other thumb to locate the spinous process immediately above it (e.Secondary Method for Identifying T1 Spinous Process – there is a less specific confirmatory method of identifying T1. For T2-T4. The thumbs should meet at the T1 spinous process. and thereby distinguishing it from C6. or immediately below it. . Secondary Method for Identifying T6 and T7 Spinous Processes – the inferior medial angle (tip) of the scapula is located approximately at the level of the T7 spinous process when the patient is seated or standing. Upper Thoracic Transverse Processes – to identify the transverse processes of T1-T4. If not. Stretch your thumbs toward each other medially. place one thumb on the spinous process. Next. place your hands on the patient’s trapezius muscles.. one thumb on the T3 spinous and the other on the T2 spinous). and at the level of the T3 spinous process when the patient is prone. Palpation: sitting or standing behind your seated patient. Remember that this is the transverse process of the more inferior of the two vertebrae. continue to palpate in small circles until you succeed. perpendicular to the spine. This secondary method for identifying the T1 spinous process may also be used when the patient is lying in the prone position. move the superior thumb laterally approximately 1-1½” to find the transverse process. and at the level of the T6 spinous process when the patient is prone. which join the neck and the point (acromion process) of the shoulder. Secondary Method for Identifying T3 and T4 Spinous Processes – the medial tip of the spine of the scapula is located approximately at the level of the T4 spinous process when the patient is seated or standing. Press down on the transverse process.g. With the patient prone. For example. Remember that this is the transverse process of the vertebra where you started this palpation. Next. move the superior thumb laterally approximately 1-1½” to . Press down on the spot that you believe to be the location of the transverse process. Lower Thoracic Transverse Processes – to locate the transverse processes of T9-T12. you would place one thumb on the T7 spinous process. continue to palpate in small circles until you succeed. to locate the T7 transverse process.Middle Thoracic Transverse Processes – to compensate for the length and downward angulation of the mid-thoracic vertebrae. The remainder of the palpation is exactly the same as for the upper and lower thoracic vertebrae. If not. either count downward from the T1 spinous process as described above or count upward from the L4 spinous process as described below. Keep it there while palpating superiorly with your other thumb to locate the spinous process immediately above it (e. one thumb on the T11 spinous and the other on the T10 spinous).g. continue further superiorward until you reach the interspinous space immediately above that spinous. place one thumb on its spinous process.. you have correctly identified the location transverse process. finally arriving at the T5-T6 interspinous space. Rather than palpating for the spinous of the immediately superior vertebra. place one thumb on the spinous process of the vertebra being evaluated. If the spinous process under your more inferiorly placed thumb moves in response to movement of the transverse process. and move the other thumb into the T6-T7 interspinous space. you can count up from the L4 spinous process. Count down to the desired spinous process. With the patient prone. With the patient prone. (Alternately. Move your superior thumb laterally approximately 1-1½” to find the transverse process. after you locate the spinous process of the vertebra being evaluated. in this case T7. then over the T6 spinous process. (Be certain to view these structures on a model spine to aid your visualization when you palpate). you will need to palpate further superiorward to locate the desired transverse process than is the case for the upper and lower thoracic zones. as described below). first locate the T1 spinous process as described above. Palpation: To identify the transverse processes of T5-T8. Keep that thumb there while palpating superiorly with your other thumb. find the transverse process. Remember that this is the transverse process of the more inferior of the two vertebrae. stretch your thumbs toward each other in a direction perpendicular to the spine. Only the lumbar vertebrae have a mamillary process. The typical lumbar vertebrae have spinous processes that are flat and broad. Then. While gripping the iliac crest. combined with the lordotic curve of the lumbar spine makes it difficult in some cases to palpate the lumbar interspinous spaces. bisect the oblique line that joins these two structures. If the spinous process of the more inferior vertebra (under your more inferiorly placed thumb) moves in response to movement of the transverse process. Spinous Process of L5 -. Once you have located the L4 spinous. The thumbs will usually meet at the level of the L4 spinous process. place the index finger of each hand on the respective iliac crest. or in some cases slightly below it at the L4-L5 interspinous space. start by locating the L4 spinous process. In most cases. Laminae of the Thoracic Spine – to locate the lamina of a thoracic vertebra. a bilateral structure located on the posterior superior lateral aspect of the superior articular process. since it is located more than an inch below the surface of the skin. To do so. and are much shorter than the typical thoracic spinous processes. Lumbar Spinous Processes (L1-L4) – to locate each of the lumbar spinous processes. If not. LUMBAR SPINE The lumbar spine consists of 5 vertebrae. you have correctly located the transverse process. arriving at the midpoint of the lamina. This procedure can be performed with the patient lying in the prone position or seated upright.to identify the L5 spinous process. To identify . In a minority of cases. count upward to identify the spinous processes between L1 and L4. slide your thumb inferiorward from the L4 spinous process (location as described above). the L5 spinous process will be readily palpable. Press down on the transverse process. first locate the vertebral segment’s spinous process and transverse process. This pattern. it is not. several muscle layers overlie this osseous structure. continue to palpate in small circles until you succeed. The mamillary process is difficult to palpate directly. which will usually cause the L5 spinous to rise up momentarily against your palpating thumb. keeping your chiropractic index finger on the L3 spinous. ischial spine and ischial tuberosity. your index finger will be over the right mamillary process of L3. broad bony landmark of the sacral base. absorbing the always present ground reaction forces. If you are still unable to feel the L5 spinous process. withstanding the compressive forces of the trunk via the 5th lumbar vertebra. Mamillary Processes of Lumbar Vertebrae (L1-L5) – to locate the right or left mamillary process of a lumbar vertebra. first locate the L3 spinous process. place the pad of your left chiropractic index finger on the spinous process of L3 and place the pad of your left index finger on the spinous process of L2.the L5 spinous in these cases. rotate your index finger 45º to the right while maintaining the same distance between the two fingers. first locate the spinous process of that vertebra (as described above). Then. the pelvis serves as a support for the vertebral column. and the L5 spinous process is directly above that and inferior to the L4 spinous process. Stand or sit on the side ipsilateral to the mamillary process you wish to identify. For example. move your thumb further in an inferior direction until you reach the firm. Anatomically. When this 45º turn is complete. This procedure can be performed with the patient lying in the prone position or seated upright. With regard to static palpation of the pelvis. . the following posterior structures are assessed: sacrum. posterior inferior iliac spine (PIIS). Ask your patient to cough. Functionally. press your thumb fairly firmly on the spot where you believe the L5 spinous will be located. Standing or sitting on the right side of the patient. the pelvis serves as an articulating connection between the trunk and lower limbs. This procedure can be performed with the patient lying in the prone position or seated upright. posterior superior iliac spine (PSIS). PELVIS The pelvis consists of the sacrum. to find the right mamillary process of L3. The L5-S1 interspace is directly above the sacral base. two (2) innominate bones and the coccyx. which is located approximately ½” inferior to L5. there are no spinous or transverse processes. revealing an inverted triangular shape. Palpation: With the patient lying in the prone position. Moving inferiorly another ¼” from the S2 tubercle is the location of the S3 tubercle and slightly below this lies the S4 tubercle. the S2 tubercle can be directly palpated by moving about ¾” inferiorly from the 5th lumbar spinous. Alternately. arriving at the sacral ala. Sacral Ala – to locate the posterior aspect of the sacral ala on a patient lying prone. Once the limits of the sacrum have been ascertained. The shape of the sacrum resembles an inverted triangle. move slightly medially and slightly superiorly. with the convexity to the posterior as seen from a side (lateral) view. and are represented by the median sacral crest. first locate the L4 spinous process (as described above) followed by the L5 spinous process (as described above). Moving inferiorly about ¼” from the S1 tubercle is the S2 tubercle. Next. Then. The bilateral sacral ala (wings) are important features of the sacral base. Instead. forming a base upon which the vertebral column lies.Sacrum – the sacrum is located immediately inferior to the 5th lumbar vertebra. The normal male sacrum is narrower and longer than the female pelvis. Gender variances exist with regard to sacral shape. The ilium is one of three sections of the innominate bone. with its base situated superiorly and its apex inferiorly. the median sacral crest can be palpated. The normal female sacrum is wider and shorter than the male sacrum. The median sacral crest is important in static palpation because the sacral tubercles that comprise it serve as landmarks to identify important osseous features of the ilia. first locate the PSIS on the ilium (as described below). starting with the 1st sacral tubercle. The adult sacrum consists of five (5) fused segments and displays a kyphotic curve. Ilia – the right and left iliac bones lie laterally to the centrally located sacrum. they serve as a stable contact point in chiropractic adjustive technique. remnants of these vertebral structures exist. the other two are the ischium and pubis. and the lateral sacral crest. feel for the sacral base immediately inferior to the 5th lumbar spinous. formed by four (4) sacral tubercles. Palpate the contour of the sacrum. . Because the sacrum is a fused structure. Palpation: With the patient lying in the prone position. Posterior Superior Iliac Spine (PSIS) – the PSIS is located at the superior aspect of the SI joint. From the S2 tubercle. at the inferior border of the buttocks. The PIIS can be difficult to palpate on some patients due to the overlying gluteal musculature. first locate the PSIS and ischial tuberosity (as described below). specifically the gluteus maximus muscle. bisect an imaginary line connecting these two osseous structures. you may need to move superiorly slightly in order to be directly over the PSIS. locate the PSIS (as described above) and move laterally ½” (over the bony ridge of the PSIS) and 1-2” inferiorly to find the PIIS. . Ischial Spine – to locate the spine of the ischium. locate the S2 tubercle on the sacrum (as described above). locate the S3 tubercle on the sacrum (as described above). palpate for the bony prominence at the level of the gluteal fold. move laterally 1½-2” to find the PIIS. The posterior superior iliac spine (PSIS) and the posterior inferior iliac spine (PIIS) can both be palpated on the bilateral ilia with a fair degree of accuracy. move laterally 1-1½” to find the PSIS. which is anatomically the posterior-most part of the iliac crest. On most patients. it is represented topographically as a pair of dimples in the skin. Then. Alternately. You may need to palpate slightly inferiorly to be directly over the ischial spine. and is much smaller than the PSIS. Ischial Tuberosity – to locate the ischial tuberosity on a patient lying prone.The sacroiliac (SI) joint is a bilateral structure bound by the sacrum on its medial surface and the two ilia on its lateral surface. From the S3 tubercle. first observe the area of transition between the gluteal and hamstring muscles. With some patients. Then. Other prominent osseous landmarks that can be palpated statically include the ischial spine and ischial tuberosity. which are both features of the ischium. Posterior Inferior Iliac Spine (PIIS) – the PIIS is located laterally and inferiorly from the PSIS. Palpation: With the patient lying in the prone position. arriving at the ischial spine. occur overnight or during the course of a 15-week college trimester. CONCLUSION Static palpation of the spine is an art and learned skill. leading to steadily increasing confidence. letting their fingers become their “new” eyes. It is a life-long task marked by increased sensitivities and perceptions through persistent practice. The ultimate goal that chiropractic students must strive for during their introductory palpation experience is to enhance their psychomotor skills by increasing tactile perception.approximately at the middle of the buttock (halfway between the medial and lateral borders of the buttock). Attainment of this goal does not. .