Spine examination

Introduction

• Wash hands
• Introduce self
• Ask Patient’s name, DOB and what they like to be called
• Explain examination and obtain consent
• Expose upper body (but leave bra on in women)
• General inspection: patient, e.g. age, pain/discomfort, signs of trauma; around bed, e.g. mobility aids, spinal brace

Look

• Gait: speed, stability, gait cycle phases, limb position/movement, abnormal gaits
• Deformities of joint/bones/alignment
  • From side: check for normal cervical lordosis, thoracic kyphosis, and lumbar lordosis; look for prominent spinous processes
  • From behind: check for scoliosis
• Skin: scars, sinuses, swellings, café-au-lait spots (neurofibromatosis), hair growth (spina bifida)
• Muscles: wasting

Feel

Ask about any pain before examining.

• Spinous processes and over sacroiliac joints for alignment and tenderness
• Paraspinal muscles for tenderness and increased tone
• Consider spinal percussion over thoracic/lumbar spinous processes, using the same technique as in a respiratory exam or closed fist percussion (percussion tenderness = serious pathology such as malignancy, osteomyelitis, or compression fracture) 

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

Move

Demonstrate movements first.

• Lateral flexion: ‘Slide your hand down your leg’
• Lumbar flexion and extension: flexion ‘Touch your toes’, extension ‘Lean backwards’
• Cervical spine movements: flexion/extension (‘Touch your chin to your chest’), rotation (‘Look over your shoulder’), deviation (‘Touch you ear to you shoulder’)
• Thoracic rotation: ‘Rotate your chest while sitting with your arms crossed’

Special tests

Schober’s test

Mark midline 10cm above the dimples of Venus and 5cm below while standing, then re-measure distance in flexion (<5cm difference implies lumbar flexion limitation that may be due to ankylosing spondylitis if there are other symptoms/signs)

Femoral nerve stretch test

With patient prone, passively flex knee and extend hip (anterior thigh pain = femoral nerve compression/irritation, usually due to L2-4 disc herniation)

Straight leg raise

With patient supine, lift a leg to full flexion or until significant leg pain, then depress it slightly and passively dorsiflex foot (leg pain radiating down below knee = sciatic nerve irritation, usually due to L4-S1 disc herniation/facet joint impingement)

Function

• (Gait: already observed)
• Brief lower limb neurological exam

To complete

• Thank patient and restore clothing
• ‘To complete my examination, I would examine the hips and perform a full lower limb neurological examination. I would also examine perianal sensation and anal tone if there was any concern about cauda equina syndrome.’
• Summarise and suggest further investigations you would consider after a full history

Try some viva questions

What are the extra-articular features of ankylosing spondylitis?

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You examine a patient with a positive sciatic nerve stretch test. What pathology does this indicate?

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Which investigations may be used to help differentiate the causes of back pain?

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What are the definitions of spondylolysis and spondylolisthesis?

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Try some OSCE stations

1. Spine exam
2. Scoliosis
3. More here!