Table of Contents
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: walking aids, speed, phases of walking, stride length, arm swing
- Inspect from behind
- Posture: asymmetry, scoliosis
- Skin and muscles: muscle wasting, scars, redness
- Soft tissue abnormalities: lipomas, hair growth (spina bifida), pigmentation, café-au-lait spots (neurofibromatosis)
- Inspect from side (stand against wall): check for normal cervical lordosis, thoracic kyphosis, and lumbar lordosis (lost in spondylolisthesis and when in pain)

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)
Move
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’
- 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) |
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) |
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
Common spine pathology
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