Musculoskeletal Spine Examination Script 2020

Score sheet – Were the Standard Examination Competencies (SEC) demonstrated? NO YES

1. Introduction Commence at: 0:00 (30s duration)

− Performs hand wash/hand rub.
− Introduces self – “My name is…. I am a first year medical student from UQ.”
− Explains purpose – “Today we are going to examine your neck and back…”
− Obtains consent – “Does that sound okay with you?”

2. Look (Inspection) Commence at: 0:30 (60s duration)

− Ensure adequate exposure, with shoes removed.
− Look around the patient’s neck and back and also check that the posture of the
shoulders and hips seem level and symmetrical.
− Report as you see e.g. “Upon inspection of the spine…”
− “There is normal posture of the cervical, thoracic and lumbar spine. The posture of
the shoulders and hips appears to be level and symmetrical.”
− “There is no deformity, spasms or torticollis.”
− “There are no scars, redness, wasting or swelling.”
− Assess gait: Ask patient to walk across the room and then walk back.
− Report findings, e.g. “The patient’s gait is normal.”

3. Feel (Palpitation) – Superficial Neck Commence at: 1:30 (60s duration)

With the patient sitting:
− Explain to patient “I am now going to feel your neck muscles and glands”
− Stand behind patient and examine – anterior/posterior triangles,
sternocleidomastoid, scalenes and superior trapezius. Ask if there is any
tenderness.
− Report findings, e.g. “Muscle bulk of the neck was normal. There was no
lymphadenopathy and no tenderness.”

4. Move – Cervical Spine Commence at: 2:30 (30s duration)

With patient standing:
− Ask patient to perform movements or demonstrate for patient to copy:
• Full flexion of cervical spine and atlanto-occipital joint (“chin on chest”).
• Full extension of cervical spine and atlanto-occipital joint (“look up to the
roof”).
• Left lateral flexion (“tilt head towards left shoulder”).
• Right lateral flexion (“tilt head towards right shoulder”).
• Left rotation (“look over left shoulder”).
• Right rotation (“look over right shoulder”).

− Note symmetry and range of movement and ask if patient has any pain.
− Report findings e.g. “The cervical spine has normal, symmetrical, active range of
movement and no pain.”

1
 5. Move – Thoracic and Lumbar Spine Commence at: 3:00 (60s duration)
With patient standing, stand behind patient and examine:
− Ask patient to perform movements or demonstrate for patient to copy:
• Full flexion of thoracic/lumbar spine (“touch toes with fingers”) – look for
scoliosis.
• Full extension (“bend backwards as far as you can”) – support patient to
prevent falling.
• Left lateral flexion (“tilt body to the left, running hand down side of leg”).
• Right lateral flexion (“tilt body to the right, running hand down side of
leg”).

Seat patient on bed, with patient’s hands behind head, stand behind patient and
examine:
• Left rotation (“twist as far as you can towards left”).
• Right rotation (“twist as far as you can towards left”).

− Note symmetry and range of movement and ask if patient has any pain.
− Report findings e.g. “The thoracic and lumbar spine has normal, symmetrical,
active range of movement and no pain.”

6. Feel (prone) – Cervical, Thoracic and Commence at: 4:00 (120s duration)
Lumbar Spine
− Lie patient in a prone position, with chest on pillow, resting forehead on hands

CERVICAL:
− Explain that you will be pushing on the neck and encourage patient to report any
pain.
− Stand at head of bed and apply pressure to spinous processes (C2-C7), using
the bimanual technique shown in the instructional videos – both thumbs are used
to apply pressure at different anatomical landmarks.

THORACO-LUMBAR:
− Explain that you will be pushing on the back and encourage patient to report any
pain.
− Move to the side of the bed and examine the paraspinal muscles, using the
technique shown in the demonstration videos:
• Use both hands, roll fingers laterally across erector spinae bands.
• Move from T1 level down to the sacrum.
• Perform on both left and right paraspinal muscle bands.
− Examine spinous processes using the pisiform grip technique shown in the
demonstration videos:
• Use the pisiform grip technique – pressure is applied through heel of
right hand (near pisiform), with left hand gripping the right thumb and
index finger).
• Apply pressure to spinous processes, moving from T1 to sacrum.
• Some practitioners will also use the bimanual technique in the thoraco-
lumbar spine.

− Report findings, e.g. “There was no midline or paraspinal tenderness.”

2
7. Femoral Nerve Stretch Test (prone) Commence at: 6:00 (60s duration)
− Explain to patient, “I will be stretching the front of your thigh by lifting your leg
off the bed. Let me know if this is painful for you and I will stop.”
− Place one hand over posterior pelvis to keep stable and feel for movement.
− Place other hand underneath patient’s knee, with knee flexed to 90 degrees.
− Extend hip to no more than 200 by raising knee vertically, relative to bed.
− Repeat on opposite leg.
− A positive test would be a reproduction of the patient’s neuropathic pain in the
anterior thigh.
− Report findings e.g. “Femoral Nerve Stretch test is negative.”

8. Straight Leg Raise (SLR) – (in supine) Commence at: 7:00 (60s duration)
Lie patient supine, with head on one pillow:
− Explain to the patient, “I will be slowly lifting your straight leg up off the bed. Let
me know if this is painful for you and I will stop.”
− Perform a slow passive straight leg raise, up to 60 degrees.
− Test unaffected side first – if patient’s sciatica symptoms occur in opposite leg,
Crossed SLR Test is positive.
− Test affected side – if patient’s sciatica symptoms occur in same leg, SLR Test
is positive.
− Additional sciatic nerve stretch can be achieved with passive ankle flexion.
− Repeat on opposite leg.
− Report findings “Straight Leg Raise testing is negative.”

9. Sacroiliac testing – Choose 3 of 5 Commence at: 8:00 (120s duration)

− Students will choose three of the five sacroiliac tests to demonstrate for their
exam. Make sure you understand how to interpret findings.

1) Thigh thrust test (in supine position):

− Explain to the patient “For this test I will be feeling over your sacroiliac joint in
your lower back while pushing your thigh towards the bed. Let me know if this is
painful for you and I will stop.”
− On the side to be tested, hip is flexed to 90 degrees and knee fully flexed.
− Wrap arm around the limb and roll the patient slightly so you can put your
fingertips over the PSIS and then let the patient relax back on the bed while you
keep your arms in position.
− Adduct the leg maximally then provide thrusting force down on the thigh.
− Ask “Does this aggravate your back pain?”

2) FABER test (in supine position):

− Explain to the patient “I will show you how to get your leg into a position a bit like
crossing your legs then I will put a bit of pressure on your knee and opposite hip.
Let me know if this is painful for you and I will stop.”
− Leg brought into flexion, abduction and external rotation with foot resting on
opposite knee.
− Stabilise opposite iliac crest and apply gentle pressure to the knee.

3
 − Ask “Does this aggravate your pain?” Note posterior pain suggests SI joint or
lumbar pathology whereas anterior pain suggests a hip pathology.

3) Pelvic distraction test (in supine position):

− Explain to patient, “For this test I will be putting pressure over your hips. Let me
know if this is painful for you and I will stop.”
− Pressure applied in a cross armed position to both ASIS.
− Ask “Does this aggravate your back pain?”

4) Pelvic compression test (side lying):

− Explain to the patient “For this test I will be pushing down on your hips. Let me
know if this is painful for you and I will stop.”
− Patient lies with affected side up.
− Hips and flexed to 45 degrees and knees to 90 degrees to stabilise the patient.
− Apply vertical downwards pressure to the ASIS.
− Ask “Does this aggravate your back pain?”

5) Sacral thrust test (in prone position)

− Explain to patient “For this test I will ask you to lie on your stomach and I will be
pressing on your lower back. Let me know if it is painful and I will stop.”
− In prone, force applied vertically to centre of sacrum, just below the line of PSIS.
− Ask “Does this aggravate your back pain?”
− Report findings e.g. “Sacroiliac testing is negative”

10. Additional Tests Commence at: 10:00 (30s duration)

− Conclude the examination and thank the patient, indicating they can redress.
− Comment on neurological testing, e.g. “I would perform a neurological
examination of the upper limb if there were issues with the cervical spine and the
lower limb if there were issues in the lumbo-sacral spine.”

11. Professional behavior (Essential to PASS)

− Confident approach to task
− Patient and assessor treated with respect.
− Provides clear instructions to patient and clear reports to assessor.
− Neatly dressed.