Examination of the spine

First, examination should be started with inspection of the patient's back while he/she is standing.

a) Inspection - Posterior



1) Is there any shoulder asymmetry?
2) Is there any prominent crease over the flanks?
3) Any scoliosis?

Postural scoliosis - scoliosis disappears when the patient is asked to bend forwards with hands touching the knee
Structural scoliosis - when asked to perform the same, scoliosis persist

4) Note whether the scoliosis is to the right or left.
5) Skin of the back, note any :

Cafe-au-lait spots : Neurofibromatosis with scoliosis
Fat pads/Hair tufts : Spina bifida
Sinus, Swelling
Scars : Previous thoracotomy (thoracogenic scoliosis)

6) Plumb line assessment :

Drop a weight from the level of the tip of spinous process of 7th cervical spine.
Measure the distance in between the tip of convexity towards the plumb line.
The greater the distance, the more severe is the scoliosis.

7) Any pelvic tilt?
8) Any wasting of gluteal muscles? Asymmetry of gluteal fold?
9) Any wasting of hamstring muscles? Calf muscles?
10) Any hindfoot deformity? (Valgus/Varus)

b) Inspection - lateral

1)  Normal thoracic and lumbar spine - Thoracic kyphosis / Lumbar lordosis
2) Gibbus

Gibbus is defined as acute angulation of the spine.
Commonly due to TB spine (Pott's disease), Congenital vertebral deformity and Vertebral fracture (traumatic or pathological)

3) Kyphosis


Regular, fixed posterior angulation of the spine. (note the difference with Gibbus - here it's regular)
Causes includes : Ankylosing spondylitis, Senile kyphosis, Osteoporosis, Scheuermann's disease

4) Lordosis


Reguar, fixed anterior angulation of spine.
Increased lordosis can be due to : Spondyloptosis or Spondylolithesis
Loss of lordosis can be due to Ankylosing spondylitis or any causes of paraspinal muscle spasm.

5) Excessive anterior abdominal protuberance

c) Inspection - anterior

1) Chest wall symmetry - rib cage prominence
2) Short trunk

Decreased distance in between the iliac crest and the subcostal margin
Caused by osteoporotic spine or even multiple vertebral fractures

3) Protuberance of anterior abdomen
4) Groin - swelling, sinus, scars
5) Attitude of lower limb

Hip - internal/external rotated, flexion, extension
Knee - Varus, Valgus deformity, flexion, extension
Ankle - Varus, Valgus deformity
Forefoot - toes deformity

Midfoot - Pes Cavus / Pes plannus

d) Palpation

If possible, ask the patient to lean forwards while you are palpating.
Check for any local rise in temperature
Palpation is done along the spinous process of the vertebras.
Note especially tenderness between spines of lumbar vertebra, lumbosacral junction.
Tenderness over sacroiliac joint may be due to mechanical back pain or infection of SI joint.
Check for any paraspinal muscle spasm, which can be protective in nature, due to PID or mechanical back pain.
Check for any renal angle tenderness.

Measure the chest wall expansion at the level of the nipples.
It should be around 5-10 cm.
It is reduced in restrictive lung diseases, scoliosis with chest deformities and ankylosing spondylitis.

e) Range of movements (Active followed by passive)

1)  Forward flexion of spine

For non-obese patients, flex to the extent of touching the knee.
Normally, it's 90 degrees.

2) Lumbar Excursion test

Place the lower end of the measuring tape at the dimple of venus.
Place the upper end 10cm above this point.
Ask the patient to flex as mentioned above.
Note the difference - normal lumbar excursion should be > 5cm

3) Extension of spine - 30 degrees
4) Lateral flexion of the spine to the right and left - 30 to 45 degrees
5) Rotation

Fix the pelvis either by asking the patient to sit down or fixing it manually when the patient is standing.
Normal : 45 degrees

f) Assess the patient's gait
g) Straight leg rising test (SLR)

As the patient is lying down supine, passively flex the hip joint by lifting the lower limb straight as shown above.
Test is positive if there's back pain which radiates down the legs, provided that the angle of elevation of less than 60 degrees.
It indicates nerve root pain.

h) Sciatic Stretch test

Continuation from the above test, bring the patient's lower limb down for about 10 degrees to relax the tension exerted on the nerve root.
Dorsiflex the ankle joint to reproduce the similar pain.

Examination is completed by Neurovascular examination of the lower limb.

Category: Orthopedics Notes