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Spinal examination
HISTORY
It is important to bear in mind the following points when performing a spinal examination:

Age of the patient

o Younger patients - instability is more common
o Older patients - osteoarthritis is more prevalent
Mechanism of injury
Character of symptoms
o Localised pain - trauma, infection, tumour
o Mechanical pain - instability
o Radicular pain - herniated disc
Onset of symptoms
Areas of numbness (saddle anaesthesia)
Bladder or bowel incontinence (Cauda Equina syndrome)
Leg pain
CLINICAL EXAMINATION

Follow the scheme below:

Inspection
Palpation
Measurement
Movement

Before starting

Introduce yourself
Ask permission to perform examination
Explain what the examination entails
Expose the patient appropriately - the patient should undress to their undergarments including the
lower limbs.
Tell the patient to let you know if anything you do is uncomfortable
Remember - always watch the patients face

Inspection

General observation
o Does the patient look well?
o Assess the patient's posture - any obvious conditions?

Patient Standing
Remember to inspect from all sides (front, laterally and from behind):

Skin

Scars (surgical scars)

o
o
o

Sinuses (deep infection)

Unusual skin creases
Pigmentation
Cafe au lait spots (Neurofibromatosis)
Hairy patch (spinal dysraphism)
Mongolian Blue spot (no clinical significance - more common in asians)

Spine

o
o
o
o

Kyphosis (exaggerated or reduced)

Lumbar lordosis (exaggerated or reduced)
Scoliosis (asymmetry of shoulder height / trunk balance / loin crease)
List ( may be sign of prolapsed intervetrbral disc causing nerve root irritation)
Asymmetry of the pelvis (leg length discrepancy)
Any chest deformity

The wall test will mask even small fixed flexion deformities: Ask the patient to stand with the back straight
against a wall. Observe whether the following are in contact with the wall:

Occiput
Shoulders
Buttocks
Heels

Patient Walking

Observe the gait

Palpation
Ask the patient..."Does it hurt anywhere?"

Palpate for tenderness

o Spinous processes - starting from cervical spine to the sacrum
o Facet joints
o Interspinous ligaments
o Sacroiliac joints
Check if there is a step or bony prominence (Spondylolisthesis, fracture)
Spasm - paravertbral muscles

Measurement
Schober's test
This is a test to determine the amount of lumbar flexion.

A mark (with a water-soluble pen) is made 10cm superior and 5cm below the Dimples of Venus small depressions on the skin on either side of the spinous processes at S2
The patient is then instructed to touch his toes
In the patient in this position, measure the distance between the two marks
If the distance between the marks is less than 5cm, there is limited lumbar flexion
If normal degree of lumbar flexion is present, the distance between the marks should be greater
than 5cm

Chest Expansion

Measue chest expansion (should measure 7cm between full inspiration and full expiration)

Movements
This should be done actively.
Cervical Spine

Flexion - "Can you bring your chin to your chest?" (Fix both shoulders to ensure movement
obtained is from the cevical spine)
Extension - "Can you look at the ceiling?"
Lateral flexion - "Can you bring your right ear to you right shoulder?" Repeat for both sides
(movement restricted in arthritis)
Lateral rotation - "Can you look over your shoulder for me?" Repeat for both sides

Thoracic spine

Rotation - "Can you twist at the waist for me?" Repeat for both sides ( Fix the pelvis - either by
asking the patient to sit down or stabilising the pelvis with both hands. Look for asymmetry)

Lumbar Spine

Flexion - "Can you touch your toes?" (Make sure that there is no flexion at the knees or hips)
o This would be a good time to test for scoliosis.
o Forward Bend test - flexion should accentuate any scoliosis by causing a rib prominence
(hump) on the convexity of the curve and a loin crease on its concavity
If the scoliosis disappears on forwards bending - postural
If the scoliosis disappears on sitting - it may be due to leg shortening
Extension - "Can you arch backwards?" (make sure the knees are kept straight)
Lateral flexion - "Can you run your hand down your thigh?" Repeat for both sides (Asymmetry in
range of movement is clinically more significant than actual range of movement)

Special Tests
Straight Leg Raise (SLR)
This is a test for sciatic nerve root irritation

With the knee extended, passively flex the hip by lifting the heel off the examination couch and
estimate the angle of elevation
Movement restricted as a result of pain radiating from the back to BELOW the knee (i.e. back,
buttock, thigh and calf) is suggestive of sciatic nerve root irritation.
Concomitant dosiflexion of the ankle can cause an increase in pain (Bragard's Test)

Bowstring Test
Test for nerve root irritation

With the hip flexed to 90 degrees, extend the knee as much as possible
Pain elicited upon the application of pressure to the hamstrings is suggestive of nerve root irritation

Femoral Nerve Stretch test

Test 2nd, 3rd and 4th Lumbar root irritation

With the patient lying on his side and the hip extended, flex the ipsilateral knee and ask the patient
whether they feel any pain. Also ask for the location and radiation of the pain.
Severe anterior thigh pain is suggestive of second, third and fourth lumbar root irritation

Finally

Check for distal neurovascular supply.

Check reflexes - knee and ankle jerks, plantars.
Perform a PR examintion:
o In trauma cases
o If there is any perianal sensory changes
o Any bladder or bowel symptoms
o If there are any upper motor neurone signs