Spine OSCE Examination

1. Introduction
2. General Inspection
3. Gait Assessment
4. Inspection (Look)
5. Palpation (Feel)
6. Movement (Move)
7. Schober’s Test
8. Straight Leg Raise (Sciatic Nerve Stretch Test)
9. Femoral Nerve Stretch Test
10. Slump Test
11. Lower Limb Neurovascular Assessment
12. Completing the Examination
13. Quiz

Wash your hands using alcohol gel or soap and water before approaching the patient.

Introduce yourself to the patient and ensure to mention your grade e.g. 3rd year medical student/junior doctor/consultant.

Confirm the patient’s details taking 3 points of identification; usually full name, date of birth and NHS/hospital number.

Obtain consent for the examination, ensuring you explain clearly what it will involve. As the spine examination requires the patient to stand, walk and move, warn them that you may ask them to do several different movements.

Expose the patient appropriately. Ideally the patient should be undressed to their underwear so that the whole spine and posture can be assessed, but always preserve their dignity and offer a chaperone.

Ask the patient if they are in any pain before you begin, and note its site and severity. This is important both for patient comfort and because the distribution of pain (for example, pain radiating down the leg) helps localise the problem.

Begin with a general inspection of the patient from the end of the bed or across the room. Look for signs that the patient is in pain or discomfort, and note their posture at rest – many patients with significant back pathology will hold themselves rigidly or shift their weight to offload a painful area.

Look for walking aids, a wheelchair, or a cervical collar, all of which give clues about mobility and the chronicity of the problem.

Note any obvious muscle wasting or asymmetry, which may suggest a chronic nerve root lesion or disuse. A generally cushingoid appearance or thin, fragile skin may hint at long-term corticosteroid use (for example in inflammatory arthritis), which is also a risk factor for osteoporotic vertebral fractures.

Look around the bedside for clues such as analgesia, TENS machines or evidence of other joint disease.

Ask the patient to walk a short distance, turn, and walk back, observing them closely. A normal gait is smooth, symmetrical and pain-free with a normal stride length.

An antalgic gait (a limp where the patient spends as little time as possible weight-bearing on the painful side) suggests a painful pathology such as nerve root irritation or hip disease.

A Trendelenburg gait, where the pelvis dips towards the unaffected side as the patient steps onto the affected leg, reflects weakness of the hip abductors (gluteus medius and minimus). Although classically a sign of hip pathology, it is directly relevant to the spine because the abductors are supplied by the superior gluteal nerve (L5), so an L5 radiculopathy can produce the same sign.

A waddling gait, in which the trunk sways from side to side with each step, points to bilateral hip abductor weakness and is typically seen with proximal myopathies (for example muscular dystrophy) rather than the spine itself, but is worth recognising.

A broad-based or unsteady gait may suggest cervical myelopathy (compression of the spinal cord in the neck), which can cause clumsiness, imbalance and difficulty walking. This is an important sign as myelopathy can require urgent surgical decompression.

Glance at the soles of the patient’s footwear as well: uneven wear can betray a long-standing abnormal gait or a leg-length discrepancy.

Where appropriate, ask the patient to walk on their heels (testing ankle dorsiflexion, predominantly L4/L5) and on their toes (testing plantarflexion, predominantly S1/S2). An inability to do so points towards a specific nerve root lesion.

If the gait is unsteady, consider performing Romberg’s test: ask the patient to stand with their feet together and then close their eyes. Marked swaying or loss of balance only once the eyes are closed (a positive Romberg’s test) indicates sensory ataxia from impaired proprioception, which in the context of the spine may reflect dorsal column dysfunction in cervical myelopathy. Always stand close enough to catch the patient if they overbalance.

With the patient standing, inspect the spine systematically from behind, from the side, and from the front, asking them to turn in stages.

From behind, look for evidence of scoliosis – an abnormal lateral curvature of the spine. Check whether the shoulders and iliac crests are level, as asymmetry may indicate scoliosis or a leg-length discrepancy. Look for any scars from previous spinal surgery and any abnormal hair tufts or skin lesions over the lower spine, which can occasionally indicate an underlying congenital abnormality such as spina bifida occulta. Note any muscle wasting of the paraspinal muscles and any bruising that might point to recent trauma.

If you suspect scoliosis, ask the patient to bend forwards as if to touch their toes (Adam’s forward bend test) and look along the back. A structural scoliosis is fixed and produces a rib hump on one side as the curve becomes more obvious on flexion. A postural (functional) scoliosis, by contrast, tends to disappear on forward bending, as it is not due to a fixed bony deformity but to a correctable cause such as a leg-length discrepancy or muscle spasm.

Image - Scoliosis, a lateral curvature of the spine. On forward flexion a structural scoliosis produces a characteristic rib hump, whereas a postural scoliosis corrects

SimpleMed original image, credit ‘SimpleMed original’

From the side, assess the normal sagittal curves. The spine normally has a gentle cervical lordosis, a thoracic kyphosis and a lumbar lordosis. Look for:

• Exaggerated thoracic kyphosis (hyperkyphosis) – seen in osteoporotic wedge fractures of the elderly and in Scheuermann’s disease in adolescents.
• Exaggerated lumbar lordosis (hyperlordosis).
• Loss of the normal lumbar lordosis (a flattened lower back), which is characteristically seen in ankylosing spondylitis and in acute muscle spasm.

A fixed, stooped, ‘question-mark’ posture with loss of lumbar lordosis and an exaggerated thoracic kyphosis is the classic appearance of advanced ankylosing spondylitis.

Image - The normal curvatures of the vertebral column: a cervical lordosis, a thoracic kyphosis and a lumbar lordosis. Recognising the normal sagittal profile makes abnormal curvatures easier to spot on inspection

Creative commons source by OpenStax College [CC BY 3.0 (https://creativecommons.org/licenses/by/3.0)]

Image - Hyperkyphosis, an exaggerated outward curvature of the thoracic spine. In older patients this is commonly due to osteoporotic vertebral wedge fractures

Creative commons source by Laboratoires Servier [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]

Before palpating, again check the patient is not in pain and watch their face for signs of tenderness as you go.

Run your fingers down the spinous processes from the cervical to the lumbar spine, feeling for alignment and any step between vertebrae. A palpable step may indicate spondylolisthesis (forward slip of one vertebra on another). Localised bony tenderness over a spinous process is a worrying sign that may indicate a fracture, infection (such as discitis or osteomyelitis) or malignancy, and should prompt further investigation.

Palpate the paraspinal muscles on either side of the midline for tenderness and spasm. Paraspinal muscle spasm is common in mechanical lower back pain.

Palpate over the sacroiliac joints. Tenderness here is a feature of sacroiliitis, which is an early and characteristic feature of ankylosing spondylitis and the other spondyloarthropathies.

Where relevant, assess the temperature of the overlying skin with the back of your hand; increased warmth may suggest active inflammation or infection.

Assess the range of movement in each region of the spine in turn. Always demonstrate the movement yourself and ask the patient to copy you, stopping if it is painful.

Cervical spine – assess:

• Flexion: ‘bring your chin down to your chest’.
• Extension: ‘look up at the ceiling’.
• Lateral flexion: ‘bring your ear down towards your shoulder’ on each side.
• Rotation: ‘turn your head to look over each shoulder’.

Reduced and painful cervical movement is common in cervical spondylosis (degenerative arthritis of the neck). Pain or paraesthesia radiating into the arm during these movements suggests cervical radiculopathy due to nerve root compression.

Thoracic spine – the main movement to assess here is rotation. Ask the patient to sit with their arms crossed (to fix the pelvis) and rotate their upper body to each side. Reduced thoracic rotation is seen in ankylosing spondylitis.

Lumbar spine – assess:

• Flexion: ‘bend forwards and try to touch your toes’. Watch the lumbar spine; it should curve smoothly. A spine that stays flat and rigid as the patient bends from the hips suggests reduced lumbar flexion, as in ankylosing spondylitis.
• Extension: ‘lean backwards’.
• Lateral flexion: ‘slide each hand down the side of the corresponding leg’.

Reduced and painful lumbar movement is a common, non-specific finding in mechanical back pain, degenerative disease and inflammatory conditions, so it should be interpreted alongside the rest of the examination.

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