Exam of the spine

Examination of the neck and spine is taught as part of Phase IIB Expanded Clinical Skills. Prior to your scheduled "hands-on" session, please review this material. You may also watch the video created by Dr. Steve Bagg, available at the Bracken library reserve desk and at the CEC. Remember to come to the session prepared to examine one another - shorts and t-shirts are advisable. There are two sessions each week; the first group should arrive at the CEC for 2 pm and the second group should arrive at 2.45.

The aim of this expanded clinical skills session is to introduce you to the core skills in regional examination of the spine necessary by the time of qualification. You will develop a systematic method for examination of the spine. Like all aspects of clinical medicine the breadth of the examination will be supplemented by wider examination in the context of the history.

The sequence described below is how we will be teaching the examination of the spine expanded clinical skills.

NB revise the RED FLAGS for back pain, normal anatomy including the spinal curves, and dermatomes.

1. Inspection. General observation of the patient at rest. Look for posture, symmetry (e.g. shoulder height, scapular prominence, waist, pelvis), skin (colour, scars, lesions, creases), muscle wasting, joint swelling.

2. Palpation. You have to know your anatomy to know what you are feeling! Include the following structures in your exam:
Skin - temperature, moisture
Soft tissues – paraspinal muscles, tendons, ligaments,
Spinous processes

2. Active range of motion. Ask the patient to move their neck in the following directions:
flexion - note chin distance to sternum
extension - note how many degrees the facial plane is beyond the vertical
rotation - note in degrees
lateral flexion - note in degrees
Also test active shoulder range of motion as neck and shoulder symptoms may overlap.

3. Passive range of motion. Only if active range not full; do in supine position.

4. Muscle stretch reflexes. Test the following reflexes:
Biceps - C5/6
Brachioradialis - C5/6
Pronator - C 6/7
Triceps - C7/8

5. Muscle power. Test the following muscle groups:
Shoulder abduction - C5/6
Elbow flexion - C5/6
Elbow extension - C7/8
Wrist extension - C6/7
Wrist flexion - C7/8
Finger extension - C7/8
Finger flexion - C8/T1
Finger abduction - C8/T1

6. Sensation. Know your C5 to T1 dermatomes. Test light touch and sharp/dull sensation.

1. Inspection; general inspection of the standing patient looking for posture, symmetry, leg length discrepancy, skin changes, muscle wasting, joint swelling.

3. Active range of motion. Ask the patient to perform the following manoeuvers:
Forward flexion - note the finger tip to floor distance
Extension - record as a % of normal
Lateral flexion - note the finger tip to floor distance or how far down the side of the leg the patient can reach.

4. Supine examination. Perform the following examinations:
Straight leg raising

Muscle power
Knee extension - L3/4
Knee flexion - L4/5
Ankle dorsiflexion - L4
Great toe extension - L5

5. Prone examination. If the history and previous findings suggest the need you may wish to examine the patient prone for;
Muscle power
Hip extension with knee flexed - S1
Prone extension test (femoral stretch test)

6. Gait. Have the patient walk normally then on their toes (tests S1) then on their heels (tests L4/5). Observe for abnormal gait patterns including (see Box 33.2, p. 645 in Clinical Surgery 2nd Edition, ed. Henry M):
Antalgic
Trendelenburg
Short leg
Foot drop

Pain Amplification/Pain Behaviours
Pain amplification and pain behavours are frequently encountered when assessing patients with neck and spinal pain. Pain amplification are signs or symptoms that appear to be out of proportion to any identifiable organic cause and include exaggerated and anatomically inconsistent sensory, motor and pain responses. This does not imply either the presence or absence of concurrent medical/physical injury or impairment.
Pain behaviours are verbal and non-verbal communications of distress or suffering including:

It is important to look for signs of pain amplification as these are flags which may identify psychological or socio-economic factors which may be influencing pain, disability and response to therapies. Early identification of pain behaviours should lead to early psycho-social interventions that may prevent a chronic pain syndrome.

Tenderness
superficial - skin is tender to gentle pinch
deep - diffuse non-specific tenderness
Simulation
Low back pain (LBP) with axial loading
LBP with truncal rotation at hips
Distraction
Straight leg raising
Poorly reproducible tenderness
Regional signs
Non-myotomal weakness
Non-dermatomal sensory disturbances
Over-reaction
Pain behaviour/amplification

"...non-organic signs can be used as a simple screen to identify patients who require more detailed psychological assessment" Waddell, 1980.