Examination of the Spine

Introduction

• Introduce yourself to the patient
• Wash your hands
• Briefly explain to the patient what the examination involves
• Ask the patient to remove their top clothing, exposing the entire spine
  • Offer the patient a chaperone, if necessary

Always start with inspection and proceed as below unless instructed otherwise; be prepared to be instructed to move on quickly to certain sections by the examiner.

Inspection

• Assess spinal alignment from an anterior, lateral, and posterior view. Check for the presence of normal spinal curvatures:
  • Excess lordosis
  • Excessive kyphosis
  • Scoliosis
• Check for:

• • Skin changes
  • Scars
  • Swelling

Palpation

• Palpate each spinous process for tenderness
  • Start with the atlanto-occipital joint and finishing at the sacroiliac joint
• Palpate the trapezius and paraspinal muscles, assessing for muscle bulk, spasm and tenderness
• Gently percuss down the spine for pain or tenderness
  • Sensitive for infection, trauma or neoplasm
• Feel for temperature down the spine

Movement

Check each part of the spine systematically

• Cervical spine*:
  • Flexion (‘chin-to-chest’) and extension (‘look at the ceiling’)
  • Lateral rotation to each side (“look over your shoulder”)
  • Lateral flexion to each side (“bring your ear down to your shoulder”)

*Ensure that the patient is either sat down, or supported, when performing these movements, as they may become unsteady

• Thoracolumbar spine:
  • Flexion, ask patient to touch their toes (for a more accurate test of this is discussed below, see Schober’s test)
  • Extension (support the patient so they don’t fall)
  • Lateral flexion, ask patient to run their arms down the side of each leg in turn
  • Lateral rotation, sit the patient on the bed (to fix the pelvis) and cross their arms, then ask to rotate from one side to the other

Special Tests

• Ask the patient to squat and rise from squatting
  • Assesses L3 (knee extensors)
• Ask patient to stand on their heels
  • Assesses L4 (ankle dorsiflexors)
• Ask the patient to lift their big toes off the ground
  • Assesses L5 (long toe extensors)
• Ask patient to stand on their tip toes
  • Assesses S1 (ankle plantar flexors)

• Schober’s test to formally assess the amount of lumbar flexion:
  • Mark 10cm superiorly from the ‘Dimples of Venus’ and 5cm inferiorly. Place your fingers on these areas. Ask patient to touch their toes
  • This gap between the 2 marks (which is currently 15cm), should increase by >5cm. Anything less than this indicates reduced lumbar flexion.
• Sciatic nerve stretch test (also called the straight leg raise test)
  • Looks for radiculopathy of the nerve roots of the sciatic nerve (L4-S3). Patient lies supine and ask them to straight leg raise
  • If the patient has sciatic nerve root radiculopathy they will get shooting pains which on minimal elevation which can be exacerbated by ankle dorsiflexion (stretching the sciatic nerve further)

Complete the Examination

In any spine examination it is essential to say that you want to do a complete upper and lower limb neurological examination and review any imaging available. Remember, if you have forgotten something important, you can go back and complete this.

For more information on dermatomes and myotomes see the International Spinal Injury Association (ASIA) Chart.