Inspect from side (stand against wall): check for normal cervical lordosis, thoracic kyphosis, and lumbar lordosis(lost in spondylolisthesis and when in pain)
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)
Demonstrate movements first.
Lateral flexion:‘Slide your hand down your leg’
Lumbar flexion (10-20˚) and extension: flexion ‘Touch your toes’, extension ‘Lean back as far as you can’
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’
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)
Chest circumference expansion
Measure chest circumference in expiration and inspiration. Around 7cm difference is normal (<5cm suggests ankylosing spondylitis).
Femoral nerve stretch test
With patient prone, passively flex knee and extend hip (anterior thigh pain = femoral nerve irritation, usually due to L2-4 disc herniation)
Straight leg raise (sciatic nerve stretch test)
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)
Gaenslen’s sacroiliac stress test
Ask patient to flex their hip and knee, then passively push that knee into the patient’s chest and push the contralateral thigh into the bed (pain = sacroiliac joint pathology)
(Gait: already observed)
Brief lower limb neurological exam
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
Common spine pathology
Try some viva questions
What are the extra-articular features of ankylosing spondylitis?
You examine a patient with a positive sciatic nerve stretch test. What pathology does this indicate?
Which neurological features would you expect in L5 radiculopathy due to disc prolapse?
Which investigations may be used to help differentiate the causes of back pain?
What are the definitions of spondylolysis and spondylolisthesis?