Spine OSCE Examination

Contents

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

Introduction

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.

General Inspection

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.

Gait Assessment

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.

Inspection (Look)

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)]

Palpation (Feel)

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.

Movement (Move)

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.

Schober’s Test

Schober’s test is a more objective way of quantifying lumbar flexion, and is particularly useful when ankylosing spondylitis is suspected.

With the patient standing upright, identify the dimples of Venus (which overlie the posterior superior iliac spines), and mark the midline at this level. Make a second mark 10 cm above and a third mark 5 cm below this point, giving a starting distance of 15 cm between the upper and lower marks.

Ask the patient to bend forwards as far as they comfortably can and measure the new distance between the upper and lower marks. In a normal spine, the distance should increase by more than 5 cm (i.e. to greater than 20 cm), reflecting normal segmental movement of the lumbar vertebrae as the spine flexes.

An increase of less than 5 cm indicates restricted lumbar flexion. This is a classic finding in ankylosing spondylitis, in which inflammation and progressive fusion of the spine reduce the ability of the vertebrae to move relative to one another.

Image - Schober’s test. Marks are made above and below the lumbosacral junction and the increase in their separation on forward flexion is measured to quantify lumbar movement

Creative commons source by Nasch92 [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

Straight Leg Raise (Sciatic Nerve Stretch Test)

The straight leg raise, also known as the sciatic nerve stretch test or Lasègue’s test, is used to detect irritation of the lower lumbar and sacral nerve roots (typically L4, L5 and S1), most commonly caused by a prolapsed intervertebral disc.

With the patient lying supine and the leg straight, slowly raise the leg by flexing at the hip while keeping the knee fully extended. This progressively stretches the sciatic nerve and its nerve roots. The test is positive if it reproduces the patient’s characteristic shooting pain radiating down the back of the leg (sciatica), usually between about 30º and 70º of hip flexion. Pain felt only in the back, or only at the very end of range, is less specific.

The finding can be confirmed with the sciatic stretch (Bragard’s) manoeuvre: at the angle that reproduces the pain, lower the leg slightly until the pain eases, then dorsiflex the foot. Because dorsiflexion further tensions the sciatic nerve, this reproduces the pain again if the nerve roots are genuinely irritated, helping to distinguish true nerve root pain from hamstring tightness.

A crossed straight leg raise, where raising the unaffected leg reproduces pain in the affected leg, is less sensitive but highly specific for a prolapsed disc.

Image - The straight leg raise. The leg is raised with the knee extended, stretching the sciatic nerve roots; reproduction of radiating leg pain is a positive result

Creative commons source by Davidjr74 [CC0 1.0 (https://creativecommons.org/publicdomain/zero/1.0)]

Femoral Nerve Stretch Test

The femoral nerve stretch test assesses the upper lumbar nerve roots (typically L2, L3 and L4), which is useful because the straight leg raise mainly tests the lower roots.

Ask the patient to lie prone. Flex the knee to about 90º and gently extend the hip, which stretches the femoral nerve along the front of the thigh. The test is positive if it reproduces pain in the front of the thigh or the inguinal region, suggesting irritation of the upper lumbar nerve roots, for example from a higher lumbar disc prolapse.

Slump Test

The slump test is another way of demonstrating nerve root irritation, and is often more sensitive than the straight leg raise. It works by progressively tensioning the neural structures from the spine down to the foot until the patient’s pain is reproduced.

Sit the patient on the edge of the couch with their thighs supported and hands clasped behind their back. Ask them to slump forwards, rounding the thoracic and lumbar spine, and then to drop their chin to their chest. Keeping them in this position, straighten the affected knee and then dorsiflex the foot, each of which adds further tension to the nerve.

The test is positive if these manoeuvres reproduce the patient’s radicular leg pain. Confirmation comes from asking the patient to lift their chin and look up: releasing the cervical flexion takes tension off the cord and nerve roots, so a genuinely positive test will ease as they do so. This points towards lumbosacral nerve root compression, again most often from a prolapsed disc.

Lower Limb Neurovascular Assessment

Because spinal pathology frequently affects the nerve roots or spinal cord, a focussed neurological assessment of the lower limbs is an essential part of the spine examination. You should assess:

• Tone – reduced tone suggests a lower motor neurone (nerve root) lesion, whereas increased tone (spasticity) suggests an upper motor neurone lesion such as cord compression.
• Power – tested in each myotome and graded on the MRC scale (0–5). Focal weakness helps localise the affected nerve root.
• Reflexes – the knee jerk (L3/L4) and ankle jerk (S1). Reflexes are typically reduced or absent in nerve root lesions, but brisk with an upgoing plantar response in cord compression (myelopathy).
• Sensation – tested in each dermatome to map any sensory loss to a particular nerve root level.

Image - The dermatomes of the lower limb. Mapping the distribution of any sensory loss to these dermatomes helps localise the affected nerve root, for example L4 over the medial shin, L5 over the dorsum of the foot and S1 over the lateral foot and sole

SimpleMed original image, credit ‘SimpleMed original’

Always check the peripheral pulses and capillary refill of the lower limbs as well. This is important because peripheral vascular disease can cause leg pain (vascular claudication) that may mimic the neurogenic claudication of spinal stenosis, and the two must be distinguished.

Crucially, if a patient with back pain reports saddle (perineal) anaesthesia, bladder or bowel dysfunction (such as urinary retention or incontinence), or bilateral leg weakness, you must consider cauda equina syndrome. This is a surgical emergency requiring urgent MRI and decompression to prevent permanent neurological damage, and assessment of anal tone and perianal sensation (a digital rectal examination) is mandatory.

Completing the Examination

Thank the patient and ensure they are comfortable and able to dress.

Wash your hands.

Summarise your findings.

To complete the examination, suggest performing a full neurological examination of the upper and lower limbs, an examination of the joint above and below (the shoulder and hip joints, as hip pathology in particular can present as back pain), and a digital rectal examination to assess anal tone and perianal sensation if cauda equina syndrome is suspected.

Relevant bedside and further investigations include basic observations, a urine dip, blood tests (including inflammatory markers such as ESR and CRP, and HLA-B27 if a spondyloarthropathy is suspected), and appropriate imaging – plain X-rays for suspected fracture or degenerative change, and MRI as the investigation of choice for nerve root compression, cord compression, infection or malignancy.

Quiz

Preview the Spine OSCE Examination quiz