Clinical Examination Guide

Spine

Components of examination

• Introduction • Look (skin, muscles, joints, deformity) – standing, gait, screening tests • Feel – spinous processes, paravertebral, chest expansion • Move - Cervical, lumbar and thoracic active movements - Schober's test for lumbar flexion • Special Tests - Straight leg raise test for sciatic nerve - Femoral nerve stretch test • Related Structures - shoulder and hip examination

Introduction

• Introduce yourself, confirm patient ID • Explain examination and the need to expose patient’s back and legs, gain consent • Ask if they have had: - any problems with their back or neck - any pain or stiffness - restriction of daily activities • Gel hands • Ask patient to stand

Look

With patient standing • Perform general inspection - check surroundings for walking aids or orthotics e.g. spinal brace, calliper, wheelchair

Examine from front, looking for: • Structural abnormalities – pectus excavatum / carinatum; level of shoulders and pelvis

From the side for: • Spinal curvature – normal/abnormal lordosis and kyphosis at cervical / thoracic and lumbar regions

Document Owner: Clinical Skills – LK/ST Last Updated: April 2018 From the back: • Skin: scars, café au lait marks (neurofibromatosis), hairy patches (spina bifida) • Muscle: spasm • Structure: scoliosis - Palate down full length of the spine - Adams forward bend test: “Please hold your palms together and bend forwards from the waist.” Palpate down full length of the spine. If the scoliosis is functional, it should correct on bending forward but a structural scoliotic curve can be more pronounced sometimes with appearance of a rib hump.

Gait: with patient walking and turning • Observe stance (heel strike, foot flat and toe off) and swing phase, symmetry, pelvic tilt – note if Trendelenburg gait

Screening Tests • Assess S1 nerve root function (plantarflexion) - “Please stand on tiptoes.” - “Now stand on tiptoe just with one foot.” - “And the other tiptoe.” • Assess L4/L5 nerve root function (dorsiflexion) - “Stand on your heels.” • Wall test - “Please stand against the wall with your head and heels touching the wall.” Look for accentuated spinal deformity. Kyphosis in ankylosing spondylitis will prevent the head from touching the wall

Feel

With the patient standing

Spinous processes • Palpate the spinous processes from occiput to sacrum, ask the patient to report tenderness. Note any temperature changes

Paravertebral • With patient standing straight, palpate the muscles either side of the spinal column • Palpate the facet joints two finger breadths to either side of midline, both sides together, asking the patient to report tenderness

Chest Expansion • Assess for upper and lower rib cage expansion using both hands in bucket (anterior-posterior) and pump handle (lateral) positions. Observe motion of your hands as the patient breathes deeply in and out

Move

Cervical With patient standing • Flexion: “Please bring your chin down to your chest.” • Extension: “Bring your head all the way back to look to the ceiling.”

With patient sitting • Rotation: “Turn your head all the way to the left … and to the right.” Check for symmetry • Lateral Extension: “Put your left ear on your left shoulder… and then the other side.” Check for symmetry

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Thoracic With patient sitting • Rotation: “Cross your arms over your chest and twist all the way round to the left ... And now to the right …”

Lumbar and Thoracic The majority of flexion and extension occurs at the upper lumbar levels while lateral flexion occurs mainly at the lower lumbar spine. Rotation is mainly a thoracic movement.

With patient standing • Forward flexion: “Keeping your knees straight, please bend forward to touch your toes.” Observe for smooth sequence of movement • Extension: “Place your hand on your hips and bend all the way back as far as you can go.” Support patient’s pelvis and note degrees of extension • Lateral flexion: “Move your left hand down the side of your thigh….and now the right hand.” Observe for symmetry

Schober’s Test for lumbar flexion With patient standing • Mark skin in the midline at level of dimples of Venus and 10cm above (L5). Anchor the top of the tape measure on upper mark and ask patient to bend forward. Measure the new distance to the lower mark. Increase is due to lumbar flexion (normal range 6-7cm increase)

Special Tests

Straight Leg Raise (SLR) for sciatic nerve Femoral nerve stretch test With patient lying supine, tell them to allow you to take With patient lying prone, tell them to allow you to take the weight of their leg the weight of their leg

• Lift the patient’s foot to flex the hip, keeping the • Passively flex the knee and extend the hip knee straight • Pain in anterior thigh = positive test • Note any limitation due to thigh or leg pain • Test further by dorsiflexing the foot • Test both sides • Observe for cross leg signs

Related Structures

• Joints above and below: Shoulder and hip • Consider neurological examination of upper and lower limbs

Conclusion

• Thank the patient, ask them to get dressed, report/record findings

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