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) 

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?

Oops! This section is restricted to members. Click here to signup!

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

Oops! This section is restricted to members. Click here to signup!

Oops! This section is restricted to members. Click here to signup!

Oops! This section is restricted to members. Click here to signup!

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

Oops! This section is restricted to members. Click here to signup!

What are the definitions of spondylolysis and spondylolisthesis?

Oops! This section is restricted to members. Click here to signup!

Try some OSCE stations

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