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.
Confirm patient details – name / DOB
Expose patient’s upper body
Position patient standing
Ask if the patient currently has any pain
Look for aids and adaptations – walking stick / wheelchair
Inspect patient from all angles
Posture of head and neck – symmetry / abnormal position
Symmetry of shoulders – note any misalignment
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
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
Observe the patient’s gait for abnormalities that may indicate spinal pathology – e.g. foot drop / antalgic gait
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.
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...
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.
Thoracic rotation– sit the patient down, with arms crossed across chest and ask to turn side to side
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.
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
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.
To complete the examination
Suggest further assessments and investigations
- Full neurovascular examination of all four limbs
- Perform further imaging if indicated – X-ray / MRI / CT
Arthritis research UK provides some excellent free guides to musculoskeletal examination and history taking [LINK]