Back (Thoracolumbar Spine) Examination

Introduction0/5

• Greetings
• Hand wash
• Verify the patient's identity using at least two or three details
• Explanation
• Consent

Look0/6

• GaitLook for antalgic gait or foot drop
• Foot drop
• Skin abnormalitiesDimples, pigmentation, or abnormal hair may indicate Spina Bifida Occulta
• Asymmetry / WastingCheck buttock folds for asymmetry
• Degree of kyphosis and lumbar lordosisAssess cervical lordosis, thoracic kyphosis, lumbar lordosis
• Scoliosis (In forward flexion)Look for lateral spine curvature during forward flexion

Palpations0/4

• Warmth / temperatureUse back of hands, compare sides
• Spinous processesKey landmarks: C7 (vertebra prominens), T3 (base of scapular spine), T7 (inferior angle of scapula), L4 (supracristal plane)
• Paraspinal muscles
• Soft tissue contours and bony landmarksCheck for step deformities or tenderness

• Movements
  • Active
    • Forward flexionNormal range 75-90°. Pain <30° suggests facet joint pathology, >30° with leg referral suggests nerve root compression/disc issues
    • ExtensionNormal range 20-30°. Lateral pain may indicate facet joint pathology (older) or pars stress (adolescent)
    • Lateral flexionNormal range 30°
    • Rotation (while stabilising hip with hand)Normal range 60°

Special tests0/10

• Schober testMark PSIS level, 5cm below and 10cm above. Should increase from 15cm to >20cm with forward flexion. <5cm increase indicates reduced lumbar flexion
• Wall testTo unmask a suspected loss of spinal extension, have the patient stand with their back against a wall, ensuring that their heels, buttocks, shoulders, and occiput all make contact with the wall surface. This position helps identify any abnormal loss of extension in the spine.
• Lumbar quadrant testPain suggests posterior element pathology on same side

• Simple power tests

  • Get up from sitting in a chair without using hands
  • Walk on heels and toes

• While sitting

  • Slump testTo screen for a disc lesion or dural tethering, have the patient sit on a couch in a relaxed posture with their legs hanging off the side. The patient should slump forward, placing their chin on their chest. Then, straighten one leg and check for any reproduction of pain radiating into the posterior thigh and leg. If pain occurs, deflex the neck to confirm whether the pain is of spinal origin. Repeat the procedure on the opposite side.

• Lying supine

  • Straight leg raiseChecks for lumbosacral root tension. Look for pain in posterior thigh, buttock, and lower back

• Lying prone

  • Femoral stretch testChecks for lumbar root tension. Positive if pain felt in anterior thigh and back
  • Palpate centrally down the spinous process from C7 to L5 using pisiform pressure looking for pain.
  • Similar to above palpate facet joints and thoracic spine costotransverse junctionFacet joints ~2cm from midline, costotransverse junctions ~4cm from midline in thoracic spine

• Mention you would do a complete lower limb neurological exam as well as assess for peripheral pulses of lower limb to complete the examination
• Wash hands