OSCE MSK Lumbar Spine

Question 1

What exposure is required for a lumbar spine examination?

Answer 1

Males: Preferred to be undressed from the waist
Females: Top is fine to remain on, may have to lift the top to allow adequate exposure of T12-L5 region

Question 2

When performing a gait assessment for the lumbar spine examination, what should be looked for (5)?

Answer 2

1. Limp (antalgic gait - short stepping on the painful side)
2. Pain - grimicing, slowed pace
3. Use of walking aids
4. Shoulder height symmetry
5. Hip height symmetry

Question 3

What 3 things are looked for on closer inspection of the lumbar spine?

Answer 3

1. Exaggerations or losses of normal thoracic and lumbar curves
2. Lateral scoliosis (if suspected, patient bend forwards to check)
3. Skin changes/scars - previous spinal surgery or traumatic injury

Question 4

What movements are performed for a lumbar spine examination?

Answer 4

Lumbar flexion
Lumber hyperextension
Lumbar lateral flexion

Question 5

How are movements of the lumbar spine described?

Answer 5

1. Range of movement:
   - Either where on the body the person can reach or in degrees
2. Presence of pain and where the pain occurred in the movement

Question 6

How is lumbar flexion performed and what is the normal range of movement?

Answer 6

Flexion – bend forward to move the fingertips toward the floor; to knees at least (Note: wide variability in normal range)

Question 7

How is extension performed in the lumbar examination and what is the normal range of movement?

Answer 7

Extension: From standing, sway backward (hands on hips or support patient at the hips to limit movement from other spinal areas/patient falling from imbalance

Range: 20-40 degrees (typically, small females will be towards the high side of the range, and large males will be towards the low side).

Question 8

How is lateral flexion performed in a lumbar examination and what is the normal range of movement?

Answer 8

Lateral flexion: Run hands up and down the outside of the thigh. Fingers to outside of knees
Range: 30-45 degrees

Question 9

What special tests are performed at the lumbar spine (2)?

Answer 9

Slump test
Straight leg raising test

Question 10

What other tests should be conducted to complete a lumbar spine examination?

Answer 10

Neurovascular examination – very important to detect signs of spinal cord compression or
aortic disease causing back pain.

Rectal examination – To test the action
of S2/3/4 – poor anal tone is a marker for spinal cord compression and a medical
emergency (this examination is not routinely done)

Question 11

What does the “measure” portion of the lumbar examination entail?

Answer 11

Flexion of the lumbar spine can be further assessed by Schober’s test

Question 12

How is the Schober’s test undertaken?

Answer 12

Patient standing,
- Identify the posterior superior iliac spines.
- In the midline, use a pen to mark this level then, with a tape measure, mark a point 10cm above, and another 5
cm below this point.
- Hold the end of the tape measure at the upper mark and ask the patient to bend forwards towards the floor (lumbar flexion); while in the flexed position, measure the distance
between the drawn marks.
- Normal: The distance will now be >20cm.
- Less than 20cm: Indicates reduced flexion of lumbar spine

Question 13

How is the slump test performed (6 steps)?

Answer 13

(Note: this test is ceased at any stage when pain occurs)

1. Sit patient on bed, legs over side, slumped forward with chin on chest. Thoracolumbar spine must be partly flexed, not just the neck.
2. Straighten the nonaffected leg first and lower
3. Straighten the affected leg
4. If no pain, straighten affected leg and dorsiflex the affected foot
5. If pain at this stage, extend the neck
6. If pain persists on neck extension this suggests pain is from hamstring
7. If pain is relieved, suggests due to disc tethering

Question 14

How is the straight leg raise (SLR) test performed?

Answer 14

1. Lie patient supine on bed.
2. SLOWLY elevate leg to 80-90 degrees at hip with knee straight, asking patient to report any pain
3. Stop elevation as soon as pain is felt; this elevation of the patient’s leg is performed by the examiner i.e. passively.

Normal – no pain in leg with lift (may have stretch sensation in hamstrings)

Question 15

What equates to a positive SLR test?

Answer 15

Positive test = pain radiating down raised leg (i.e. reproducing the pain that the patient
presented with).
Passively dorsiflexing the foot (Lasѐgue’s test) accentuates the pain (done very carefully; painful)

Is due to disc prolapse pressing on spinal nerve roots, which causes pain that worsens as nerve is stretched across prolapse

Question 16

How is hamstring pain different to lower back pain?

Answer 16

Hamstring pain feels different
- It is not felt in the back
- It is a stretching feeling rather than the shooting pain that occurs with nerve stretching
- Is not as severe and does not settle with neck extension (in slump test)

Question 17

List the five areas of the lumbar spine that are felt during palpation?

Answer 17

1. Iliac crests (found easily if moving from ASIS posteriorly)
2. L4 and L5 (line drawn between iliac crests will be in between these)
3. Spinous processes of lumbar spine
4. Paravertebral muscles (palpate tip of rib 12, then find muscles just medial and inferior)
5. Sacroiliac joints

Question 18

How are the landmarks palpated in the lumbar examination?

Answer 18

• Prone; Ask the patient to place their hands under their forehead so that the neck is not rotated.
• Stand well over patient, with arms straight.
• Use thumb tips (pulps) to press 3-4 times over each midline spinous process
• Do the same laterally (one thumbs breadth) over the facet joints at level of spinous process
• Palpate the paravertebral muscles for tenderness +/- spasm
• Palpate over the sacroiliac joints.

Question 19

What should be done during the “feel” portion of the lumbar examination, in terms of positive findings?

Answer 19

Make note of any level that is tender
Where relevant, clarify if tenderness is in the midline, or on the right or left side.
Also, make note of tenderness of spasms of the paravertebral muscles

Question 20

What is opposite the PSIS?

Answer 20

S2 is opposite posterior superior iliac spines (marked by dimples)

Question 21

How do you locate the PSIS?

Answer 21

The PSIS marks the posterior edge of the iliac crest and manifests in some individuals as dimples on the lower back

In prone, easily found by moving superior and medially with the thumbs from the mid part of the fleshy part of the buttocks.

Try to feel up and under the PSIS on each side. You are at the level of S2