Spine examination

Question 1

Special tests in spine examination?

Answer 1

Schober’s test
Sciatic stretch test
Femoral nerve stretch test

Question 2

Schober’s test

Answer 2

Schober’s test can be used to identify restricted flexion of the lumbar spine, which may occur in conditions such as ankylosing spondylitis.

1. Identify the location of the posterior superior iliac spine (PSIS) on each side.
2. Mark the skin in the midline 5cm below the PSIS.
3. Mark the skin in the midline 10cm above the PSIS.
4. Ask the patient to touch their toes to assess lumbar flexion.
5. Measure the distance between the two lines.

If a patient has normal lumbar flexion the distance between the two marks should increase from the initial 15cm to more than 20cm.

Reduced range of motion is associated with conditions such as ankylosing spondylitis.

Question 3

Sciatic stretch test?

Answer 3

The sciatic stretch test is used to identify sciatic nerve irritation.

Assessment
1. Position the patient supine on the clinical examination couch.

2. Holding the patient’s ankle, raise their leg by passively flexing the hip whilst keeping the patient’s knee fully extended.
3. The normal range of movement for passive hip flexion is approximately 80-90º.
4. Once the patient’s hip is flexed, dorsiflex the patient’s foot.

The sciatic stretch test is considered positive if the patient experiences pain in the posterior thigh or buttock region.

A positive test is suggestive of sciatic nerve irritation (e.g. secondary to lumbar disc prolapse).

Question 4

Femoral nerve stretch test?

Answer 4

The femoral nerve stretch test is used to identify femoral nerve irritation.

1. Position the patient prone on the clinical examination couch.
2. Flex the patient’s knee to 90º and then extend the hip joint.

The femoral nerve test is considered positive if the patient experiences pain in the thigh and/or inguinal region.

Question 5

Completion of spinal examination?

Answer 5

Neurovascular examination of the upper and lower limbs.
Examination of the hip and shoulder joints.
Further imaging if indicated (e.g. X-ray/MRI).

Question 6

LOOK aspect of spine examination?

Answer 6

GAIT: signs of discomfort, asses symmetry and turning, gait cycles, antalgic gait in sciatic
FRONT: head and neck posture, symmetry of shoulders
SIDE: Cervical lordosis, thoracic kyphosis, lumbar lordosis
BEHIND: Scars, muscle masting, scoliosis, abnormal hair growth

Question 7

FEEL aspect of the spine examination?

Answer 7

Palpate spinal processes (alignment, irregularitis, tenderness) with two fingers
Palpate sacroiliac joints
Palpate paraspinal muscles (tenderness, spasam)

Question 8

MOVE aspect of spine exam?

Answer 8

Active cervical extension (look up)
Active cervical flexion (look down)
Active cervical rotation (look left and right, keeping shoulders still)
Cervical lateral flexion (ear to shoulder)
Lumbar flexion (bend forward touch toes)
Lumbar lateral flexion (bend laterally running hand down leg towards foot)
Lumbar extension (lean back as far as you can)
Thoracic rotation (cross arms rotate upper body)

Question 9

Normal ROM cervical flexion?

Answer 9

0 to 80 degrees

Question 10

Normal ROM cervical flexion?

Answer 10

0-50 degrees

Question 11

Normal ROM cervical rotation?

Answer 11

0 to 80 degrees

Question 12

Cervical lateral flexion normal ROM?

Answer 12

0 to 45 degrees

Question 13

Normal ROM lumbar extension

Answer 13

10-20 degrees

Question 14

Normal ROM thoracic roation?

Answer 14

10-20

Question 15

What does abnormal hair growth around the spine region suggest?

Answer 15

Abnormal hair growth: may indicate underlying bony abnormalities such as spina bifida.

Question 16

Spine appearance on lateral inspection?

Answer 16

Cervical lordosis: hyperlordosis is associated with chronic degenerative joint disease (e.g. osteoarthritis).
Thoracic kyphosis: the normal amount of thoracic kyphosis is typically between 20-45º. Hyperkyphosis is associated with Scheuermann’s disease (congenital wedging of the vertebrae).
Lumbar lordosis: loss of normal lumbar lordosis is associated with sacroiliac joint disease (e.g. ankylosing spondylitis).

Question 17

What causes trendelenburg’s gait?

Answer 17

Trendelenburg’s gait: an abnormal gait caused by unilateral weakness of the hip abductor muscles secondary to a superior gluteal nerve lesion or L5 radiculopathy.

Question 18

What causes waddling gait?

Answer 18

Waddling gait: an abnormal gait caused by bilateral weakness of the hip abductor muscles, typically associated with myopathies (e.g. muscular dystrophy).

Question 19

Management of AS?

Answer 19

Medication:

NSAIDs can be used to help with for pain. If the improvement is not adequate after 2-4 weeks of a maximum dose then consider switching to another NSAID.
Steroids can be use during flares to control symptoms. This could oral, intramuscular slow release injections or joint injections.
Anti-TNF medications such as etanercept or a monoclonal antibody against TNF such as infliximab, adalimumab or certolizumab pegol are known to be effective in treating the disease activity in AS.
Secukinumab is a monoclonal antibody against interleukin-17. It is recommended by NICE if the response to NSAIDS and TNF inhibitors is inadequate.
Additional management:

Physiotherapy
Exercise and mobilisation
Avoid smoking
Bisphosphonates to treat osteoporosis
Treatment of complications
Surgery is occasionally required for deformities to the spine or other joints

Question 20

AS X ray changes?

Answer 20

“Bamboo spine” is the typical exam description of the xray appearance of the spine in later stage ankylosing spondylitis. This is worth remembering for your exams.

Xray images in ankylosing spondylitis can show:

Squaring of the vertebral bodies
Subchondral sclerosis and erosions
Syndesmophytes are areas of bone growth where the ligaments insert into the bone. They occur related to the ligaments supporting the intervertebral joints.
Ossification of the ligaments, discs and joints. This is where these structures turn to bone.
Fusion of the facet, sacroiliac and costovertebral joints