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case
Clinical Skills Booklet
Case 24 – Spine Examination

Learning outcomes

 Demonstrate examination of the back using a systematic look, feel, move, function
approach
 Demonstrate palpation of surface landmarks of the back
 Palpate the spinous process of vertebra C7 and the posterior superior iliac spine, and
count vertebrae

Examination Structure

 Introduction
 Patient identification
 Gain Consent
 Obtain a chaperone if required
 Look
 Feel
 Move
 Special Tests
 Function

Inflammation

Joint pain can be an inflammatory or non-inflammatory process. It is therefore important to be

able to identify the cardinal signs of inflammation.
 Pain
 Heat
 Redness
 Swelling
 Loss of function
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Pain

 It is important to establish whether the patient is experiencing any pain in any of his/her
joints prior to commencing your examination.

 If the patient has been experiencing pain, ensure that you start away from the site of
pain.

 Remember to watch the patient carefully during your examination for any signs of
discomfort or if any existing pain becomes worse during the examination

Inspection of the spine (Look)

With patient standing straight inspect from all angles, assessing:

 Alignment, i.e. cervical lordosis, thoracic kyphosis, lumbar lordosis
 Deformity, e.g. scoliosis
 Muscle bulk/wasting
 Asymmetry
 Skin changes/erythema
- Note if changes are symmetrical or asymmetrical

Feel
Palpate the spinous processes
 Alignment
 Tenderness

Palpate the sacroiliac joints

 Alignment
 Tenderness

Palpate the paraspinal muscles

 Tenderness
 Areas of increased tone
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Move

Lumbar flexion and extension

 With two hands, palpate two adjacent lumbar spinous processes, the spinous process
should separate indicating the movement is coming from lumbar spine and not solely
the hip joints
 Ask the patient to bend and touch their toes, then lean backwards (make sure you are
supporting the patient)
Lateral flexion of thoracolumbar spine
 Ask the patient to run each hand down the outside of the adjacent leg

Cervical spine movements

 Flexion: Chin to chest
 Extension: Look to the ceiling
 Lateral flexion: ear to shoulder (correct the patient if they compensate by moving their
shoulder up to their ear)
 Rotation: look over each shoulder in turn

Rotation of the thoracic spine

 Patient sitting on the edge of the examination couch to fix their pelvis
 Assess rotation, using your hands on the patient’s shoulders to guide the
movement
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Special Tests

1. Straight leg raise

 With the bed flat and patient supine lift one straight leg off the bed - ask if this is
painful
 Subsequently dorsiflex the foot of the raised leg
 If dorsiflexion of the foot causes back pain then it is likely due to nerve root
entrapment/irritation
2. Assess limb reflexes
 Of both upper and lower limbs

3. Assess distal lower limb power

 Power of dorsiflexion of the great toe

4. Assessment of peripheral pulses.

If any neurological symptoms in history, a full upper and lower limb neurological
examination should be performed. Consider performing a digital rectal examination (DRE).

References

Douglas et al: Macleod’s Clinical Examination, 12th Edition. 2009 by Churchill Livingstone

https://www.versusarthritis.org/about-arthritis/healthcare-professionals/video-
resources/regional-examination-of-the-musculoskeletal-system/examination-of-the-spine-
video/

All images used in handout are courtesy of Elsevier. All rights reserved, used with permission,
do not distribute
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