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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Try some viva questions

Try some OSCE stations

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