Spine examination

Question 1

What is the first part of any introduction to an examination?

Answer 1

Wash hands
Intro self
Pt details

Question 2

Explain a spine exam to a patient

Answer 2

I’ve been asked to examine your spine today, it’s going to involve me having a general inspection, feel, asking you to perform some movements and then performing some special tests, would that be okay?

Question 3

What else would you include in your intro?

Answer 3

Expose ok?
Chaperone?
Pain or discomfort?

Question 4

What do you inspect in a spine exam?

Answer 4

Bedside
Front
Side
Behind
Scars

Question 5

When inspecting the bedside what are you looking for?

Answer 5

Any aids or adaptations / Walking stick or wheelchair.

Question 6

When inspecting from the front what are you looking for?

Answer 6

Posture of the head and neck;
Symmetry/abnormal position.
Symmetry of shoulders -> Any misalignment?

Question 7

When inspecting from the side what are you looking for?

What do changes indicate?

Answer 7

Assess for cervical hyperlordosis
Spondylolisthesis (slipped vertebrae),
Spondylosis (osteoarthritis).

Assess for thoracic hyperkyphosis (>45°) –
Vertebral fracture.

Assess for lumbar hyperlordosis;
Obesity/tight lower back muscles.

Question 8

When inspecting from the back what are you looking for?

What do changes indicate?

Answer 8

Scars
May indicate previous surgery/trauma.

Wasting of paraspinal/back muscles
May suggest chronic immobility.

Scoliosis

Café-au-lait spots
Neurofibromatosis.

Sacral dimple/ naevus/ hairy patch
Spina bifida.

Question 9

When inspecting the gait what are you looking for?

Answer 9

Is the patient demonstrating a normal heel strike/toe off gait?

Is each step of normal height?

Is the gait smooth + symmetrical?

Any obvious abnormalities –
Antalgic/waddling/broad-based.

Question 10

How should you position the patient on the couch after inspecting gait?

What do you do?

Answer 10

Position the patient supine on the couch with hips + knee extended

Question 11

Which the patient in this supine position what should you do?

Answer 11

Inspect
Palpate the spinal processes, sacroiliac joints and paraspinal muscles

Question 12

Why do you palpate the spinal processes, sacroiliac joints and paraspinal muscles?

Answer 12

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.

Palpable lumbosacral junction may indicate spondylolisthesis.

Tenderness over the sacroiliac joints may indicate ankylosing spondylitis.

Question 13

What else should you palpate?

Why?

Answer 13

Palpate the thyroid, supraclavicular fossae + cervical lymph nodes for any masses

Cervical rib, lymph glands, tumours.

Question 14

What movements do you assess in the cervical spine?

What should you ask the patient to do for each?

Answer 14

Flexion (80°) – “Can you touch your chin to your chest?”

Extension (50°) – “Now look up at the ceiling”.

Lateral flexion (45°) – “Touch your ear to your shoulder”.

Rotation (80°) – “Turn your head to left to right”.

Question 15

In what condition is restriction in lateral flexion common and rotation is restricted and painful?

Answer 15

cervical spondylosis

Question 16

If there is restricted cervical rotation what do you do?

Answer 16

Perform passively with one hand on the neck to feel for crepitus and the other on the top of the head for movement

Assess if pain/stiffness/muscle spasm is the restricting factor.

Question 17

What movement do you assess in the thoracic spine?

What should you ask the patient to do?

Answer 17

Thoracic rotation (45°)

Sit patient down with arms crossed across chest + ask them to turn side to side.

Question 18

What movements do you assess in the lumbar spine?

What should you ask the patient to do for each?

Answer 18

Flexion / Schober’s test;
Identify the posterior superior iliac spine (dimples
of Venus).
Mark the skin in the midline 5cm below PSIS and
10cm above creating a 15cm line.
Ask patient to touch their toes
Normally the distance increases by at least >5cm.
Normally fingers <7cm from ground.

“Try touching your toes keeping your legs straight”.

Extension (25° thoracic, 35° lumbar)

“Lean backwards as far as possible”.

Lateral flexion
Ask patient to stand straight with hands by their
side and feet 30cm apart.
Measure distance from finger tips to floor.
Difference between the two measurements is the
amount of lateral flexion and should be >10cm.

“Slide your hand down the outer aspect of your leg as far as you can, keeping your legs straight”.

Question 19

For the lumbar extension what does a restricted / painful response indicate?

Answer 19

prolapsed intervertebral disc + spondylosis

Question 20

What might reduced ROM indicate in Schober’s test?

Answer 20

Ankylosing spondylitis.

Question 21

When percussing:
a) what do you ask the patient to do?
b) what do you percuss
c) what does tenderness indicate?

Answer 21

a) Ask the patient to bend forward

b) Lightly percuss the spine from the root of the neck to
the sacrum

c) Infection, fractures + neoplasia.

Question 22

How do you carry out straight leg raise/sciatic stretch test?

What is a positive test?

What can this indicate?

Answer 22

Position patient supine on bed.
Hold ankle + raise leg (passively flexing hip) while the knee is straight.
Lower the leg gradually until the pain disappears then dorsiflex the foot to increase tension on nerve roots, aggravating the pain/paraesthesia.

Positive test if patient experience posterior thigh/buttock pain.

Paraesthesia or pain in a nerve root distribution indicates nerve root irritation like sciatica.
Back pain suggests a central disc prolapse.
Lower the leg gradually until the pain disappears then dorsiflex the foot to increase tension on nerve roots, aggravating the pain/paraesthesia.

Question 23

How do you carry out the bowstring test?

What is a positive test and what does it indicate?

Answer 23

Flex hip and if patient experiences pain then flex knee slightly + apply pressure with thumb in popliteal fossa to stretch the tibial nerve;

Radiating pain + paraesthesia suggests nerve root irritation.

Question 24

How do you carry out a femoral nerve stretch?

What is a positive test?

Answer 24

Position patient prone.
Flex knee + extend hip.
Plantarflex the foot

Positive test if pain felt in anterior thigh/inguinal region

Question 25

How do you test for suspected ankylosing spondylitis?

What is a positive test?

Answer 25

Assess chest expansion at fourth intercostal space (normal 3–5cm)

Reduced in ankylosing spondylitis.

Question 26

Upon completing the exam what do you do first?

Answer 26

Thank patient
Wash hands

Question 27

To complete my exam…

Answer 27

I’d like to perform a full neurological and vascular examination of the patients upper and lower limbs, examine the hip and shoulder joints, examine the peripheral pulses and in a patient with lower back pain perform an abdominal examination and consider a rectal examination

Question 28

Summarise a normal spine exam

Answer 28

Today I performed a spine examination on ____ a __ year old ____

On general inspection, ___ appeared comfortable at rest.

No abnormalities were detected on inspection.

There was normal gait.

On palpation, there was no tenderness.

Full range of movement in all modalities tested.
Special tests were negative.

To conclude, this is consistent with a normal spine examination