Examination of the Back

The examination of the entire spinal column is lengthy and, where appropriate, certain sections may be omitted e.g. for sake of time in an OSCE situation.  Otherwise, it is not a bad idea to examine the entire spine so nothing is missed (Usually, in an OSCE station, you would focus on just one or two of these but state what else you would like to do).  It is important (NB in particular, with cervical and lumbar spine examinations) to carry out a corresponding neurological examination of the limbs too.

Cervical Spine

Look

1. With the patient exposed down to below the shoulder, look at the neck for any deformity (e.g. loss of lordosis, which can be caused by muscle spasm)

Feel

1. Palpate down the midline spinous processes from the occiput to T1 (the most prominent)
2. Feel also the paraspinal soft tissues, supraclavicular fossae, anterior neck structures (including thyroid)
   1. Note any tenderness of the spine, trapezius, paraspinal muscles and interscapular muscles; any lymph node enlargement; or any deformity/mass of the neck.

Move

1. Assess active movements first:
   1. Forward flexion (normal 0° to 80°); extension (normal 0° to (-)50°); lateral flexion (normal 0° to 45° in each direction); lateral rotation (normal 0° to 80°)
2. If there is reduced active movement, test passive movement gently.
   1. Note the features of movement e.g. limited gradually/suddenly, pain/stiffness etc

Thoracic Spine

Look

1. With the patient exposed from the waist up and standing, inspect the thorax from front, back and side, noting any deformity, scars etc.

Feel

1. Palpate the midline spinous processes T1-T12
   1. Any notable prominence may be a sign of a wedge-collapse e.g. of osteoporosis
2. Palpate the paravertebral muscles and paraspinal soft tissue and note any tenderness.

Move

1. With the patient sitting and arms crossed, ask the patient to turn from side to side, testing thoracocolumnar rotation.

Lumbar Spine

Look

1. With the patient standing and the back fully exposed, inspect the lumbar spine for deformity, any abnormal curvature, scars etc

Feel

1. Feel the spinous processes and paraspinal soft tissues of the lumber and sacral spine (L4/5 is at the level of the iliac crest)
2. Gently percuss the spine with a closed fist (warn the patient first) and note any tenderness.

Move

1. Ask the patient to try and touch their toes with their legs straight , testing flexion of the lumbar spine.
   1. Record how far down the patient can reach.
2. Ask the patient to lean back to test extension (normal range is 10° to 20°)
3. Ask the patient to reach their hand down the side of their leg as far as possible, testing lateral flexion.

Other Tests

1. Schober’s test (forward flexion)
   1. With a pen, mark the skin in the midline at the level of the dimples of Venus.  These are the indents in the contours of the skin with overlie the sacroiliac joints.
   2. Measure and mark 10cm above and 5cm below this point.
   3. With a tape measure fixed at the upper mark, ask the patient to touch their toes (legs straight, as before).
      1. The distance between the two marks drawn in (B) should increase from 15cm to >20cm.
2. Straight leg raise(L4, L5 and S1 nerve root tension- sciatic nerve)
   1. With the patient lying on a couch/bed, passively lift the foot to flex the hip, keeping the knee extended.
      1. The normal range of movement is 0° to 80/90° (limited by pain).  If the patient complains of marked pain a while before that is reached, record the range of movement.
      2. Move the leg down just below where pain starts and gently dorsiflex the foot.  This stretches the sciatic nerve and if L4-S1 are responsible, pain should return.
   2. To test for functional overlay (i.e. if test is true positive), you can carry out the flip test.
      1. With the patient sitting at the edge of the bed, examine the knee reflexes (as a distraction) and extend the knee as if to examine the ankle reflex.
         1. A patient with radiculopathy should lie back due to the pain.  A functional patient will usually have no problem.
3. Tibial Nerve Stretch(L4, L5, S1, S2, S3)
   1. With the patient lying on a couch/bed, partially flex the hip and extend the knee so the the hamstring tendons ‘bowstring’ across the popliteal fossa.
   2. Gently press over the hamstring tendons with your thumb, then gently press over the tibial nerve in the centre of the popliteal fossa.
      1. The test is positive when pain is felt when the nerve is pressed but not when the tendons are pressed.
4. Femoral Nerve Stretch(L2, L3, L4)
   1. With the patient lying prone, flex the knee and extend the hip.
      1. Test is positive if pain is felt in the anterior thigh.