Spine Examination

Spine Examination (sem 5 MSK)

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Flow of events

1.       GIEP

2.       Wash hands

3.       Observe Gait

4.       Inspection of spine

a.       Front

b.      Lateral

c.       back

5.       Palpation of spine

a.       Cervical spine

b.      Paravertebral tissues

6.       Movements

a.       Cervical spine

b.      Thoracic spine

c.       Lumber spine

7.       Special tests (nerve root compression)

a.       Shober’s test

b.      Straight leg raising test + Lasague’s sign

c.       femoral nerve stretch test + reverse lasague’s sign

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Gait observation

Ask patient to walk to a certain point. Observe for any abnormal gait.

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Inspection of spine

·         Ask patient to stay standing

·         Ask patient to remove their upper gown.

·         Inspect for any asymmetry in his/her standing position - is it symmetrical?

·         Inspect from the front

o   Any why neck (torticollis)? - SCM contracture

o   Lateral flexion (cock robin position) - erosion of lateral mass of atlas in RA

·         Inspect from the lateral side

o   Any kyphosis (bending of spine in anterolateral direction) ? - more pronounced kyphosis seen in Ankylosing Spondylitis and osteoporosis

o   Any Kyphus / Gibbus? (angulation at a localized area of spine)  - caused by previous fracture / pott’s spine

·         Inspect from the back

o   Any scoliosis? (bending of spine in lateral direction) - may be congenital, due to Prolapsed Intervertebral Disk muscle spasm, or inequality in leg length. If you suspect the leg length inequality, ask patient to be seated - where the scoliosis will disappear.

o   Any tufts of hair along the spine? - suggests spina bifida - important in patients complaining back pain / numbness

o   Any scars, swellings, soft-tissue damage, discolouration etc.

• look for neurofibromas, cafe-au-lait spots as NF is associated with scoliosis 

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Palpation of spine

·         vertebra

o   major landmarks are

§  C7 (vertebra prominens),

§  T3 to T7 - scapula

§  L4 - iliac crests

§  S2 - PSIS

o   tap on the spine to try and elicit spinal tenderness (spinal inflammation due to osteomyelitis, septic arthritis of spine, etc)

o   neck bertebra pain may be due to supraspinous damage following whiplash injuries or may also indicate more major neck trauma.

·         paravertebral tissue

o   press on the erector spinae muscle for any muscle spasm (IVDP pain muscle spasm etc)

sacroilliac joint - faver test (press on the knee downwards while you ask them to sit cross-legged... like a man.) always test this for lower back problems. 

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Movements (report as you go)

·         cervical spine

o   lateral rotation (normal range 80deg)

§  look to the right / left without moving body

o   Lateral flexion (normal range 45deg)

§  touch ear to shoulder without shrugging

o   Extension  (normal range 50deg)

§  look to ceiling

o   Forward flexion (normal range 80deg)

§  look down without bending body

·         thoracic spine rotation (normal range 45deg)

o   ask patient to put hands on their hips, and rotate as much as they can while seated

ask patient to stand up

·         thoracolumber spine

o   flexion

§  ask patient to try and touch their toes, without bending knees. If their finger reach below level of patella, considered normal. You may measure the finger’s height from floor.

o   Extension

§  Ask patient to try and bend backwards without bending their knees. Make sure that they won’t fall over.

o   Lateral flexion

§  Ask patient to run their fingers down the sides of their body, without bending knees.

§  Usually the first to be reduced in Ankylosing spondylitis.

Limitation of movement of lumber spine almost always should be investigated for serious pathology e.g.  infection - staphylococcal / TB discitis, inflammation - ankylosing spondylitis, reiter’s, enteropathic, psoritic arthritis etc etc.

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Special tests

·         Schober’s test

o   This test tests the ability of the spine to flex forwards.

o   Ask patient to stand upright, locate the 2 Dimple of Venus (PSIS) - in between that is the L5. put a point 10cm above the L5, and 5cm below L5, and hold onto the 10cm point above the L5, keeping in mind where the 5cm point was. Ask patient to bend forward, and the tape measure should read more than 5cm increase in between the previous-15cm length of the length of the back.

·         Straight leg raising test

o   Ask patient to lie flat

o   Ask patient to raise leg until a pain is ilicited. - normally, the range of motion should be around 90 degrees. If markedly below this level, straight leg raising test is positive and there may be a sciatic nerve compression (e.g. due to IVDP)

o   To comfirm, dorsiflex the foot after lowering the leg a little bit. If pain is observed, it is comfirmatory (lasague’s sign positive)

·         Femoral nerve stretch test

o   With the patient prone and the anterior thigh fixed to the couch, flex each knee in turn. This causes pain in the appropriate distributions by stretching the femoral nerve roots in L2-L4.

o   The pain produced is normally aggravated by extension of the hip.

o   The test is positive if pain is felt in the anterior compartment of thigh.

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remember the tendon reflex myotomes.

offer for DRE - for anal tone (for any spine lesion)