- Observe the patient standing. Look initially from behind the patient for any obvious muscle wasting, asymmetry, or scoliosis of the spine.
- Look from the side for normal cervical lordosis, thoracic kyphosis, and lumbar lordosis.
- Feel down the spinal processes and over the sacroiliac joints for alignment and tenderness.
- Palpate the paraspinal muscles for tenderness.
- Assess lumbar flexion and extension by placing two or three fingers over the lumbar spine. Ask the patient to bend to touch their toes. Your fingers should move apart during flexion and back together during extension (see Figure 8).
- Ask the patient to run each hand in turn down the outside of the adjacent leg to assess lateral flexion of the spine.
- Next, assess the cervical spine movements. Ask the patient to: tilt their head to each side, bringing the ear towards the adjacent shoulder (lateral flexion); turn their head to look over each shoulder (rotation); bring their chin towards their chest (flexion); and tilt their head backwards (extension).
- With the patient sitting on the edge of the couch to fix their pelvis and their arms crossed in front of them, assess thoracic rotation (with your hands on the patient’s shoulders to guide the movement) (see Figure 19).
- With the patient lying as flat as possible, perform straight leg raising (see Figure 20). Dorsiflexion of the foot with the leg raised may exacerbate the pain from a nerve root entrapment or irritation such as that caused by a prolapsed intervertebral disc.
- Assess limb reflexes (upper and lower) and dorsiflexion of the big toe.
A brief neurovascular examination should be carried out including assessment of upper and lower limb reflexes, dorsiflexion of the big toe, and assessment of peripheral pulses. If there has been any indication from the history of a relevant abnormality, a full neurological and vascular assessment – including sensation, tone and power – should also be made.
Examination of the spine: checklist
- Introduce yourself/gain consent to examine
With the patient standing:
- Inspect from the side and from behind
- Palpate the spinal processes and paraspinal muscles
- Assess movement: lumbar flexion and extension and lateral flexion; cervical flexion, extension, rotation and lateral flexion
With the patient sitting on couch:
- Assess thoracic rotation
With the patient lying on couch:
- Perform straight leg raising and dorsiflexion of the big toe
- Assess limb reflexes
CMC(J) carpometacarpal (joint); CT computerized tomography; DEXA dual-energy x-ray absorptiometry; DIP(J) distal interphalangeal (joint); ESR erythrocyte sedimentation rate; GALS gait, arms, legs and spine; MCP(J) metacarpophalangeal (joint); MRI magnetic resonance imaging; MTP(J) metatarsophalangeal (joint); NSAID non-steroidal anti-inflammatory drug; OA osteoarthritis; PIP(J) proximal interphalangeal (joint); RA rheumatoid arthritis; REMS regional examination of the musculoskeletal system.