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Spine examination frequently appears in OSCEs. You’ll be expected to pick up the relevant clinical signs using your examination skills. This spine examination OSCE guide provides a step by step approach to examining the spine, with an included video demonstration. Check out the spine examination mark scheme here.



Introduction

Wash hands

Introduce yourself

Confirm patient details – name / DOB

Explain examination

Gain consent

Expose patient’s upper body

Position patient standing

Ask if the patient currently has any pain


Look

Look for aids and adaptations – walking stick / wheelchair

Inspect patient from all angles

Front

Posture of head and neck – symmetry / abnormal position

Symmetry of shoulders – note any misalignment 

 

Side

Cervical lordosis – assess for hyper-lordosis – spondylolisthesis / osteoporosis / discitis 

Thoracic kyphosis – normal is 20-45º – hyperkyphosis (>45º) – vertebral fracture

Lumbar lordosis – assess for hyperlordosis –  obesity / tight lower back muscles 

 

Behind

Scars – can provide clues as to previous surgery/trauma

Wasting – paraspinal muscles/other muscles of the back – may suggest chronic immobility

Scoliosis – lateral curvature of the spine – resembles an “S” shape

Abnormal hair growth – spina bifida 

Assess Gait

Observe the patient’s gait for abnormalities that may indicate spinal pathology – e.g. foot drop / antalgic gait

 

  • Inspect from the front

Feel

Palpate spinal processes and sacroiliac joints – assess for tenderness and alignment

Palpate paraspinal muscles – note any tenderness or muscle spasms

Observe the patient’s face as you perform the above, looking for signs of pain.

  • Palpate the spinal processes

Move 

Cervical spine

Assess active movements:

Flexion – “touch your chin to your chest” – normal ROM 0-80º

Extension – “look up at the ceiling” – normal ROM 0-50º

Lateral flexion – “touch your ear to your shoulder” – normal ROM 0-45º

Rotation – “turn your head to the left and then to the right” – normal ROM 0-80º

Perform passive movements if reduced ROM on active movement.

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

  • Cervical extension
    Cervical extension
..

Lumbar spine

Assess active movements:

Flexion – “touch your toes, keeping your legs straight”

Extension -“lean backwards as far as possible”  – normal ROM 10-20º

Lateral flexion – “slide your left hand down the outer aspect of your left leg as far as possible, keeping your legs straight” – repeat the test using the right hand/leg

  • Lumbar flexion
    Lumbar flexion
.

Thoracic spine

Thoracic rotation– sit the patient down, with arms crossed across chest and ask to turn side to side 

  • Thoracic rotation
    Thoracic rotation

Special tests

Schober’s test tests the range of motion in the lumbar spine

1. Identify position of the posterior superior iliac spine (PSIS) – “dimples of Venus”

2. Mark the skin in the midline 5cm below  PSIS

3. Mark the skin in the midline 10cm above PSIS

4. Ask the patient to touch their toes –  full lumbar flexion

5. Measure the distance between the two lines (started at 15cm)

Normally the distance between the two marks should increase to >20cm.

Reduced range of motion can indicate conditions such as ankylosing spondylitis.

  • Mark the midline at the level of the PSIS

Sciatic stretch test – (straight leg raise)

1. Position the patient supine on the bed

2. Holding the ankle, raise the leg (passively flexing the hip) – keeping the knee straight

3. Normal ROM is approximately 80-90º of passive hip flexion

4. Once the hip is flexed as far as the patient is able, dorsiflex the foot

5. The test is positive if the patient experiences pain in the posterior thigh/buttock

If this causes pain in lower back /thigh/ buttocks, it suggests sciatica

  • straight leg raise
    Perform a straight leg raise

Femoral nerve stretch test

1. Position the patient prone

2. Flex the knee

3. Extend the hip

4. Plantar-flex the foot
Positive test  = pain felt in thigh/ inguinal region.

  • Femoral nerve stretch test
    Femoral nerve stretch test

To complete the examination

Thank patient

Wash hands

Summarise findings

Suggest further assessments and investigations

  • Full neurovascular examination of all four limbs
  • Perform further imaging if indicated – X-ray / MRI / CT

Further reading

Arthritis research UK provides some excellent free guides to musculoskeletal examination and history taking [LINK]


REVIEWED BY 

Mr Tejas Yarashi

Trauma & Orthopaedic Surgeon (ST7)


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