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
- Chest circumference expansion
- Femoral nerve stretch test
- Straight leg raise
- Gaenslen’s sacroiliac stress 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)
Measure chest circumference in expiration and inspiration. Around 7cm difference is normal (<5cm suggests ankylosing spondylitis).
With patient prone, passively flex knee and extend hip (anterior thigh pain = femoral nerve irritation, usually due to L2-4 disc herniation)
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)
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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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 neurological features would you expect in L5 radiculopathy due to disc prolapse?
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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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