Added by Feroz Dinah , May 2004
- Scars: previous surgery
- Lumps: abscess, tumour (e.g. sacral lipoma), prominent paravertebral muscle spasm
- Sinuses: deep infection
- Cafe au lait spots / nodules: Neurofibromatosis
- Hairy patch (spinal dysraphism)
- Mongolian blue spot (more common in Asians: no clinical significance)
- Low hairline due to short neck: Klippel-Feil syndeome: fusion or absence of cervical vertebrae; may be associated with Sprengel shoulder (undescended scapula)
- Down / Morquio syndromes: Atlanto-axial instability
- Asymmetry of shoulder height / trunk balance / loin crease: scoliosis (lateral curvature with rotational deformity of vertebral bodies)
- Leg length discrepancy (check level of iliac crests)
- If patient consistently stands with one knee bent in spite of equal leg lengths, this may indicate nerve root tension, as knee flexion relieves the pull on the nerve root(s)
- Lateral deviation of spine (known as 'list' or 'tilt'): may be a sign of prolapsed intervertebral disc causing nerve root ompression
- Associated anomalies of hands/feet, e.g. syndactyly, pes cavus: may be part of a syndrome
- Kyphosis and lordosis (best assessed from side): may be exaggerated or reduced
- Round backing / hunched shoulders: Schuermanns disease/kyphosis
- Gibbus (aka kyphos): acute angular deformity with bony prominence, e.g. tuberculous vertebral collapse
- Observe gait
- Tenderness: may be bony, intervertebral or paravertebral
- Bony prominence or steps
- Flexion: Ensure spinal rather than hip flexion, by marking two spots about 10cm apart on the patient lumbar spine: these should separate by a further 5cm on flexion.
- Forward bend test: Flexion should accentuate any scoliosis by causing a rib prominence (aka rib hump) on the convexity of the curve and a loin crease on its concavity.
- If the scoliosis disappears on forward bending, it is postural.o If the scoliosis disappears on sitting, it may be due to leg shortening.
- Scoliosis may be secondary to nerve root compression and will therefore disappear after resolution (spontaneous or surgical), i.e. sciatic scoliosis
- Extension: Ask patient to arch backwards, but beware of cheating by trick movement of bending knees.
- The wall test will unmask even small fixed flexion deformities: Ask patient to stand with his/her back against a wall. Observe if heels, buttocks, shoulders and occiput all touch the wall.
- Lateral flexion: Ask patient to run hand down ipsilateral thigh on one side, and then the other. Asymmetry in range of movement is clinically more significant than actual range of movement
- Rotation: Again, of little clinical significance, but as most rotation occurs in the thoracic spine, this should not be reduced in lumbo-sacral disease. Stabilise the patients pelvis with both hands, and ask the patient to twist/turn to either side, looking for asymmetry of range of movement.
- Rib cage excursion: This should be about 7cm between full inspiration and full expiration.
The books are full of normal ranges of neck movements in degrees, but you have to ask the patient to put something in his/her mouth to act as a goniometer. It may be more useful to use (less precise) anatomical landmarks to gauge range of movement. Also, CHANGES in ranges of movement are often more useful.
- Flexion: Most people can get their chin on their suprasternal notch.
- Extension: should allow nose or forehead to be parallel to ceiling.
- Rotation: cheek parallel to shoulder.
- Lateral flexion: very variable, and first movement to be restricted in arthritis.
1. Rotation occurs throughout C-spine, but mainly at atlantoaxial joint (C1/C2).
2. Flexion / extension occurs throughout the C-spine (C0 to C7).
3. No flexion in thoracic spine, because splinted by ribcage.
4. No rotation in lumbar spine, because facet joints are vertical.
- Watch the patient climb on the examination couch.
- Focal spinal tenderness
- [Assess sensation on back of whole leg; if worried about cauda equina syndrome, perianal sensation may also be assessed here.]
- Check popliteal and posterior tibial pulses
- Femoral nerve stretch: Either acutely flex the knee with the thigh resting on the couch, or extend the hip with the knee in moderate flexion. If pain is elicited, there is a positive nerve stretch test.
- [Assess hip rotation and ankle reflexes with the knee at 90o of flexion.]
- Watch the patient turn over onto his/her back.
- Sensation can be tested here [or at the end, in the neurological examination]
- Assess hip/knee mobility if you haven't already.
- Straight leg raise (SLR): keep the knee extended and passively flex the hip by lifting the heel off the examination couch and estimate the angle of elevation (normally 80 - 90o). If restricted by pain radiating from back to BELOW the knee (i.e. back, buttock, thigh and calf), there is evidence of sciatic nerve root irritation. Tension on the sciatic nerve can be increased by dorsiflexion of the ankle, causing increase in pain.
- Lasegue's test: Tension is then removed by flexing the knee, often allowing the hip to be fully flexed. If when the knee is extended from this flexed hip/knee position, the pain is reproduced, Lasegue's test is positive.
- Bowstringing's test: With hip flexed to 90o, extend the knee as far as the patient tolerates. Pressure applied to the hamstrings (possibly pulling on the peroneal nerve) with the thumb will immediately cause pain if there is nerve root irritation.
NOTE: If the pain on SLR is felt in the contralateral limb (cross-leg pain or cross-sciatic tension), there may be a central disc prolapse, with risk of cauda equina syndrome.
Signs of nerve root compression
Standard full neurological examination of both lower limbs, i.e. tone, power (MRC grading), sensation (light touch, pinprick and proprioception if indicated) and reflexes. Usually deficit(s) will follow an anatomical distribution, i.e. dermatome(s) or myotome(s). Whole limb pain, weakness, or anaesthesia suggest supratentorial overlay.
Non-organic signs (Waddell G. et al. Non-organic physical signs in low back pain. Spine 1980; 5: 117)
1. Superficial / non-anatomical tenderness: Lightly pinch the skin on a wide area of lumbar skin (pinch test). If this causes pain, test is positive.
2. Axial loading: Using the flat of his/her hands, the examiner vertically loads the patient's skull. If this causes pain, the test is positive. Similarly, simultaneous ipsilateral rotation of shoulders and pelvis (i.e. log-roll) in the same plane should NOT cause pain.
3. Distraction: If the examiner elicits severe pain on SLR, but the patient is able to comfortably sit forward with legs extended on examination couch, the test is positive. (aka 'flip' test in USA)
4. Regional disturbances: Test is positive in presence of non-anatomical motor or sensory deficits (e.g. normal heel-toe walk, but cog-wheel foot weakness).
5. Over-reaction: Test is positive if muscle spasm, tremor or collapse occur during examination