Examination of the Spine Flashcards
What is involved in the intro to the spinal exam?
Wash your hands
• Introduction, identification and consent
• Before commencing, ask the patient whether they have any pain in their neck or back.
What are the stages of the examination of the spine?
Inspection Palpation Assesing Range of Motion Completion Optional special tests
What is involved in the inspection stage of the spinal examination?
Inspect the patient from in front, from the side and from behind. Adequate exposure of the
spine is essential, and the patient should therefore be dressed in their bra and pants.
• Inspect the patient’s skin, looking for café-au-lait spots, which may suggest
neurofibromatosis, a sacral dimple, naevus or hairy patch suggestive of spina bifida
occulta, or scarring suggestive of a previous thoracotomy or spinal surgery.
• Inspect the cervical spine for deformity (e.g. cervical spondylosis, acute torticollis). An
abnormal head posture may be due to disease in the cervical spine or neck, but you
should also consider other causes e.g. extraocular muscle palsy. Look for asymmetry
of the clavicles, scapulae and shoulders.
• Inspect the thoracolumbar spine for kyphosis or scoliosis
What is involved in the palpation stage of the spinal examination?
Palpate for tenderness over the spine and soft tissues.
• Palpate the cervical spine and neck posteriorly in the midline, laterally, and anteriorly,
Examine the supraclavicular fossae for any masses (e.g. cervical rib, lymph glands,
tumours) and the paraspinal muscles for tenderness.
• Palpate the thoracolumbar spine and sacrum for tenderness. Tenderness between the
spines of the lumbar vertebrae, at the lumbosacral junction and over the lumbar
muscles may occur with a prolapsed intervertebral disc and with mechanical back pain.
• A palpable step at the lumbosacral junction may indicate spondylolisthesis.
• Palpate for tenderness over the sacroiliac joints (e.g. ankylosing spondylitis).
What is involved in assessing the range of motion in the spinal exam?
Assess the active ROM of the cervical spine.
o Flexion: normal range 80°, chin able to touch sternoclavicular joint.
o Extension: normal range 50° (note: flexion and extension primarily involve the
atlanto-axial and atlanto-occipital joints).
o Lateral flexion: normal range 45° from midline. Restriction of lateral flexion is
common in cervical spondylosis.
o Lateral rotation: normal range 80° to both sides. Rotation is restricted and painful
in cervical spondylosis.
Please note: If there is restriction of any active cervical spine movement then
cautiously check passive range of motion to identify if there is any further increase
in the range of motion. Ask the patient to perform the active movement and then
cautiously, with one hand on the neck to feel for crepitus and the other hand on the
top of the head to create the movement, slowly and gently attempt to passively
move the cervical spine beyond the active range.
• Assess the movement in the thoracic and lumbar spine
• Flexion is due to a combination of thoracic, lumbar and hip movements. The
composite movement may be recorded as the distance between the patient’s
fingers and the ground (normally < 7cm) or the lowest level that the person can
reach (e.g. mid-tibia).
A modified Schober’s test should be used to provide a quantitative evaluation of
flexion of the lumbar spine. Mark a 15cm length of the lumbar spine with the patient
in the erect position), measuring 10cm above and 5cm below the posterior superior
iliac spines (Dimples of Venus). Instruct the patient to flex his or her spine
maximally. Re-measure the distance between the marks. Normal flexion increases
the distance by at least 5 cm.
o Extension. Ask the patient to arch their back (normal range = thoracic 25°, lumbar
35°). Pain and restricted extension are particularly common in prolapsed
intervertebral disc and spondylolysis.
• Lateral flexion. Ask the patient to stand erect with hands at their sides and feet
30cm apart. Measure the distance from the finger tips to the floor. Ask the patient
to flex maximally to the side and re-measure the distance from the finger tips to
floor. The difference between the two measurements is recorded as the amount
of lateral flexion (normal >10cm). The contributions of the thoracic and lumbar
spine to lateral flexion are usually equal.
• Rotation. The patient should be seated, asked to fold their arms across their chest
then asked and to twist round to each side. The normal range of rotation is 40°
and is almost entirely thoracic. The lumbar contribution is <5°.
• Ask the patient to bend forward and lightly percuss the spine from the root of the neck
to the sacrum. Significant percussion tenderness is a feature of infection, fractures and
neoplasia.
• Assess the patient’s gait
What special tests should be performed in a suspected prolapsed intervertebral disc and what do they involve?
• Straight leg raise. Ask the patient to lie flat on the couch. Passively flex their thigh with their leg extended. If the patient complains of back or leg pain the test is positive (hamstring tightness is not relevant). Paraesthesiae or pain in a nerve root distribution indicates nerve root irritation. Back pain suggests, but is not indicative of, a central disc prolapse, and leg pain suggests a lateral protrusion. Lower the leg gradually until the pain disappears then dorsiflex the foot. This increases tension on the nerve roots, aggravating any pain or paraesthesiae (Lasegue’s sign).
• Bowstring test: Perform a straight leg raise. If the patient experiences pain, flex the knee
slightly then apply firm pressure with the thumb in the popliteal fossa to stretch the tibial
nerve. Radiating pain and paraesthesiae suggest nerve root irritation.
• Femoral stretch test: With the patient prone and the anterior thigh fixed to the couch, flex each knee in turn. This causes pain in the skin overlying the anterior compartment of the thigh by stretching the femoral nerve roots in L2-L4. The pain produced is normally
aggravated by extension of the hip.
what special test can we do in suspected ankylosing spondylitis?
Assess chest expansion at the level of the fourth intercostal space (normal = 3-5cm). This
may be reduced in ankylosing spondylitis.
How do we complete a spinal exam?
Perform a full neurological examination of the patients upper and lower limbs, looking
for fasciculation, wasting, and abnormalities in tone, power, reflexes and sensation.
Remember that cervical spinal cord compression may lead to bladder and bowel
disturbance, lower limb neurological dysfunction and abnormal gait.
• In a patient presenting with lower back pain, perform an abdominal examination to
identify any masses, and consider a rectal examination (omit in the OSCE) to check
for loss of anal tone and perianal sensation (cauda equina syndrome).
• Examine the peripheral pulses as vascular claudication in the upper and lower limbs
may mimic the symptoms of radiculopathy or canal stenosis.
• In patients presenting with neck pain, you should also examine the shoulder joints. In
patients presenting with lower back pain you should examine the hip joints.
Osteoarthritis of the hip may present with predominantly back and buttock pain as well
as with pain in the groin.
Thank the patient
• Request them to redress
• Wash your hands
