CHAPTER IV

SPINE EXAMINATION

Spine examination
 1. I will introduce myself to the patient
2. Before I examine the patient, I will wash my hand
3. I ask the patient “may I undress ?”
4. I start the examination

Standing Anterior
 I ask the patient to walk, and then we evaluate the gait of the patient  evaluate
from front, beside and back
 Gait of the patient is normal (think about gait analysis)
 The patient still in the standing position and we start observe from

LOOK
1. Anterior : Center of head, and evaluate the SCM, sternoclavicular joint, symmetricity
of the shoulder, level of the papilla mammae and sign of the maturation. I also
evaluate the symmetricity of the pelvis.
2. Lateral : evaluate the sagittal balance of the center head, the lordotic cervical spine,
kyphotic thoracic spine, Lordotic lumbar spine. I also look if there’s any wound, scar,
deformity, bruise, lump.
3. Posterior : evaluate the center of head, the SCM from posteriorly, symmetricity of
the shoulder, level of scapula, distance between the medial border of scapula to
spine, Gluteal Fold. I look for cafe au lait and hairy patch, symmetricity of the pelvic.

Anterior Lateral Posterior

Café au lait
macules Hairy patch

Take the plum line, and check the coronal balance :

 - From coronal plane (posterior side), I identify C7 spinous process and check the
location of the end of the plum line. Normally 1 cm medial or lateral to sacrum.

FEEL
1. Anterior : lump in neck, SCM, sternoclavicular joint
2. Lateral : Lump in neck, SCM
3. Posterior : Check the spinous process, check the borders of scapula and tip of angle.

Take the water pass, I ask the patient to bend forward to flex the spine, and if there is
any hump, I measure the distance to
spine.

NEUROVASCULAR
Check the sensory status 
Check the motoric function :
C4: Shoulder shrug
C5: Shoulder abduction
C6: Elbow flexion, wrist extension
C7: Elbow extension, wrist flexion
C8: Flexion of MCPs
T1: Fingers abduction and adduction
L2: Hip flexion
L3: Knee extension
L4: Ankle dorsiflexion
L5: Great toe extension
S1: Ankle plantar flexion
 Check the vascular status of the patient
- Colour of the distal, compare to contralateral side
- Temperature, compare to contralateral side
- CRT <2’
- Feel pulse of radial artery
- Saturation

MOVEMENT
1. Flexion  90o / tip of finger 7 cm from floor
2. Extension  20 – 30o
3. Lateral bending  arm is close to the body and bend the trunk laterally, 30o
4. Twist (rotation)  from waist, 30o
0
30

Special Test
1. Schober’s Test is performed with the patient in a standing position, and I identify the
4th lumbar spine and mark two points, 10 cm proximally and 5 cm distally and ask
the patient to bend forward again. If there is no change in the distance between two
points or no increase distance more than 5 cm, it means there is restriction in the
lumbar flexion.

Schober’s test
2. Straight Leg Raise : differentiated pain from the hip or the spine (note : make sure
that there is no hip problem like OA before do this examination, by doing ROM hip
with knee flexion 90 degrees and knee flexion 90 degrees  no pain  no oa, pain
 oa, negative for SLR test)
 supine position
 knee fully extension
 elevated the until 60 degrees of hip flexion, evaluate is there any pain? 
(+) , back pain or leg pain, not the hamstring tightness  nerve root irritation
 continued with laseque test
 downward the hip flexion until the pain subside
 dorsiflexion the ankle  (+) pain  impingement positive, sciatic stretch test
(+), if (-) hip problem

Straight leg raise Laseque test

 or perfom bowstring test (after elevated the hip until pain is reached  slight
flexion of the knee apply pressure with the thumb in the popliteal fossa 
stretch the tibial nerve  nerve root irritation

Bowstring test
 3. Thomas test
 Supine the patient lying in the bed
 Square the pelvic
 (examiner at affected side)
 One hand in the lumbar  to make sure the lordotic of the lumbar region
 Flexion of the contralateral side until lumbar lordotic disappear
 Evaluation is there any flexion  measure the degree of the flexion
contracture

Thomas test

Physiology reflex : increasing due to loss of inhibition mechanism

Upper extremity :

- Biceps reflex
- Sat on the examining table, the practitioner holds the patient’s arm at the elbow,
and places his/her thumb over the patients Biceps Brachii tendon.
- The practitioner than strikes his/her own thumb using a reflex-hammer.

- Triceps reflex
- Performed by tapping the triceps tendon with the sharp end of a reflex
hammer while the forearm is hanging loose at a right angle to the arm.
- A sudden contraction of the triceps muscle causes extension, and indicates a normal
reflex.

Lower extremity :
- Patellar reflex
- Identify the patellar tendon, a thick, broad band of tissue extending down from the
lower aspect of the patella (knee cap).
- Strike the tendon directly with your reflex hammer. If you are having trouble
identifying the exact location of the tendon (e.g. if there is a lot of subcutaneous fat),
place your index finger firmly on top of it. Strike your finger, which should then
transmit the impulse.
- Achilles reflex
- Identify the Achilles tendon, a taut, discrete, cord-like structure running from the
heel to the muscles of the calf.
- Position the foot so that it forms a right angle with the rest of the lower leg.
 - Strike the tendon directly with your reflex hammer. A normal reflex will cause the
foot to plantar flex (i.e. move into your supporting hand).

Pathologic reflex :  pyramidal disruption

- Hoffman - tromner

Hoffman reflex Tromner reflex

- Babinski test
- Run metal edge of neurlogic hammer, or fingernail along the plantar surface of the
foot from the calcaneus, along the lateral border of the foot to the forefoot
- Positive Test
- Great toe extension with flexion and splaying of the lateral four toes
- Positive Test Implications  Upper motor neuron lesion
- Chaddock test
- Run metal edge of neurlogic hammer, or fingernail along the lateral malleolus of the
foot
- Positive Test
- Great toe extension with flexion and splaying of the lateral four toes
- Positive Test Implications  Upper motor neuron lesion

- Oppenheim test
- Run metal edge of neurlogic hammer, or fingernail along the tibial crest
- Positive Test
- Great toe extension with flexion and splaying of the lateral four toes
- Positive Test Implications  Upper motor neuron lesion

- Clonus  extrapyramidal, pyramidal and cerebellum disruption

Provocative test
1. Lhermitte test
Patient should be awake and cooperative to assess for Lhermitte’s Sign.

 Patient should be seated or supine during the procedure.

 The examiner passively flexes the head forward using gentle pressure.
  The examiner checks for any pain while maintaining pressure over the back of
the head.

Positive  there is sharp pain

characterized by pain shooting down
the spine or extremities  indicate the
presence of cervical myelopathy.

Lhermitte test

2. Spurling test

 Patient slowly extend, sidebend and rotate the head to the affected side.
 The examiner give gentle downward pressure to the head of patient.
 Radiating pain in the same side from the neck to the arm of patient.

Spurling test

OSCE Checklist : Examination of the Spine

Introduction
Introduce yourself
Briefly explain the procedure and get consent from the patient
Wash hand
Ask the patient to remove their clothing, exposing the body and hip
Look
Patient gait
Anterior: center of head, and evaluate the SCM, sternoclavicular joint, symmetricity of the
shoulder, level of the papilla mammae and sign of the maturation. Evaluate the symmetricity of
the pelvis.
Lateral: evaluate the sagittal balance of the center head, the lordotic cervical spine, kyphotic
thoracic spine, lordotic lumbar spine. Look if there’s any wound, scar, deformity, bruise, lump.
Posterior : evaluate the center of head, the SCM from posteriorly, symmetricity of the shoulder,
level of scapula, distance between the medial border of scapula to spine, Gluteal Fold. Look for
cafe au lait and hairy patch, symmetricity of the pelvic.

Check the coronal balance (using plumb line)

Feel
Anterior: tenderness, lump, crepitation and false movement in the neck, SCM and sternoclavicular
joint
Lateral: tenderness, lump, crepitation and false movement in the neck, SCM
Posterior : Check the spinous process, check the borders of scapula and tip of angle.

Check the neurovascular status properly

Sensory function of the upper and lower extremity
Motoric function of the upper and lower extremity
Vascular status of the upper extremity
Movement
Check passive and active movement
Flexion – Extension
Left – Right lateral flexion
Twist from waist ( Internal – External rotation)
Special test
Schober’s test
Straight Leg Raise test
Laseque test
Thomas test
Lhermitte test
Spurling test
Perform physiological reflex correctly
Perform patholological reflex correctly
Completing the examination
Thank the patient and allow them to redress