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11/13/24, 7\:10 PM Guide | Spine examination

Spine examination

Table of contents
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0\:00 5\:09

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Gain consent to proceed with the examination.
Adequately expose the patient’s upper body and provide a blanket to cover the patient when not being examined.
Position the patient standing for initial inspection of the spine.
Ask the patient if they have any pain before proceeding with the clinical examination.

Look

General inspection

Clinical signs
Perform a brief general inspection of the patient, looking for clinical signs suggestive of underlying pathology\:
Body habitus\: obesity is a signi
Scars\: may provide clues regarding previous spinal surgery.
Wasting of muscles\: suggestive of disuse atrophy secondary to joint pathology.
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Objects or equipment
clinical status\:
Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
Aids and adaptations\: examples include walking aids and wheelchairs.
Prescriptions\: prescribing charts or personal prescriptions can provide useful information about the patient’s recent
medications (e.g. analgesia).

Closer inspection of the spine

Ask the patient to stand and turn in 90° increments as you inspect the spine from each angle for evidence of pathology.
Anterior inspection
Inspect the anterior aspect of the spine, noting any abnormalities\:
Scars\: note the location of the scar as this may provide clues as to the patient's previous surgical history or suggest previous
trauma (e.g. anterior neck scar due to anterior cervical discectomy).
Posture\: note any asymmetry which may indicate joint pathology or scoliosis.
Asymmetry of the shoulder girdle\: may be caused by scoliosis, arthritis, fractures or dislocation.
Pelvic tilt\: lateral pelvic tilt can be caused by scoliosis, leg length discrepancy or hip abductor weakness.
Lateral inspection
Inspect the lateral aspect of the spine, noting any abnormalities\:
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).
Posterior inspection
Inspect the patient from the behind noting any abnormalities\:
Spinal alignment\: inspect for lateral curvature of the spine indicative of scoliosis.
Iliac crest alignment\: misalignment may indicate a leg length discrepancy or hip abductor weakness.
Muscle wasting\: note any wasting of the paraspinal muscles which may indicate chronic spinal pathology and reduced
mobility.
Abnormal hair growth\: may indicate underlying bony abnormalities such as spina bi
Bruising\: suggestive of recent trauma or surgery.
Inspect from the front
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Gait

Ask the patient to walk to the end of the examination room and then turn and walk back whilst you observe their gait paying
attention to\:
Gait cycle\: note any abnormalities of the gait cycle (e.g. abnormalities in toe-o
Range of movement\: often reduced in the context of chronic joint pathology (e.g. osteoarthritis, in
Limping\: may suggest joint pain (i.e. antalgic gait) or weakness.
Leg length\: note any discrepancy which may be the cause or the result of joint pathology.
Turning\: patients with joint disease may turn slowly due to restrictions in joint range of movement or instability.
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.
Waddling gait\: an abnormal gait caused by bilateral weakness of the hip abductor muscles, typically associated with
myopathies (e.g. muscular dystrophy).
Assess the patient’s footwear\: unequal sole wearing is suggestive of an abnormal gait.
Observe gait cycle
Gait cycle
The gait cycle has six phases\:
1. Heel-strike\: initial contact of the heel with the
2. Foot
3. Mid-stance\: the weight is aligned and balanced on this leg.
4. Heel-o
5. Toe-o
6. Swing\: the foot swings forward and comes back into contact with the
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Stages of the gait cycle (1-5)

Feel

Palpate the spinal processes and sacroiliac joints, assessing their alignment and noting any tenderness.
Palpate the paraspinal muscles noting any tenderness or muscular spasms.
Palpate the spinal processes
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Move

For each of the movements described below, assess active movement and if abnormalities are identi
movements passively.
Active movement refers to a movement performed independently by the patient. Ask the patient to carry out a sequence of
active movements to assess joint function. As the patient performs each movement, note any restrictions in the range of the
joint's movement and also look for signs of discomfort. It's important to clearly explain and demonstrate each movement you
expect the patient to perform to aid understanding.
Passive movement refers to a movement of the patient, controlled by the examiner. This involves the patient relaxing and
allowing you to move the joint freely to assess the full range of joint movement. It's important to feel for crepitus as you move
the joint (which can be associated with osteoarthritis) and observe any discomfort or restriction in the joint's range of
movement. If abnormalities are noted on active movements (e.g. restricted range of movement), assess joint movements
passively.

Cervical spine

Flexion of the cervical spine
Normal range of movement\: 0°
- 80°
Instructions\: Ask the patient to touch their chin to their chest.
Extension of the cervical spine
Normal range of movement\: 0°
- 50°
Instructions\: Ask the patient to look up at the ceiling.
Lateral
Normal range of movement\: 0°
- 45°
Instructions\: Ask the patient to touch their ear to their shoulder on each side.
Rotation of the cervical spine
Normal range of movement\: 0°
- 80°
Instructions\: Ask the patient to turn their head to the left and the right.
Active cervical extension

Lumbar spine

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Flexion of the lumbar spine
Instructions\: Ask the patient to touch their toes whilst keeping their legs straight.
Extension of the lumbar spine
Normal range of movement\: 10°
- 20°
Instructions\: Ask the patient to lean back as far as they are comfortably able, whilst you're positioned close to them for support
if required.
Lateral
Instructions\: Ask the patient to slide their left hand down the outer aspect of their left leg as far as they are able to whilst
keeping their legs straight. Then ask them to repeat by sliding their right hand over their right leg.
Active lumbar

Thoracic spine

Rotation of the thoracic spine
Instructions\: Ask the patient to sit on the side of the clinical examination couch and cross their arms across their chest. Then
ask them to turn to the left and the right as far as they are comfortably able to.
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Active thoracic rotation

Special tests

Schober’s test

Schober's test can be used to identify restricted
ankylosing spondylitis.
Assessment
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
5. Measure the distance between the two lines.
Interpretation
than 20cm.
If a patient has normal lumbar
Reduced range of motion is associated with conditions such as ankylosing spondylitis.
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Mark the midline at the level of the PSIS

Sciatic stretch test (a.k.a. straight leg raise)

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
3. The normal range of movement for passive hip
.
4. Once the patient's hip is
Interpretation
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).
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Perform a straight leg raise

Femoral nerve stretch test

The femoral nerve stretch test is used to identify femoral nerve irritation.
Assessment
1. Position the patient prone on the clinical examination couch.
2. Flex the patient's knee to 90º and then extend the hip joint.
3. Finally, plantar
Interpretation
The femoral nerve test is considered positive if the patient experiences pain in the thigh and/or inguinal region.
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