OnExam

Inspection

  • Inspect patient in standing: anteriorly, posteriorly and laterally
    • Gait (arm swing, rotation)
    • Postural deformities (exaggerated kyphosis, scoliosis
    • Muscle atrophy, spasm or increased tone
    • Shoulder height
    • Scapulae (resting position, winging, anterior shoulder posture/abducted scapula)
    • Height where hands hang

Palpation

  • Note areas of pain, swelling, spasm, atrophy, deformity or crepitus in the following structures:
    • Each thoracic spinous process form T1-T12
    • Facet joints deep in paraspinal muscles from T1-T12
    • Paraspinal muscles
    • Scapulae: place hand on each scapula and patient flexes forward to 45˚, height of hands should remain symmetrical but if asymmetry then suggestive of scoliosis
    • Cervical spine
    • Lumbar spine

Percussion

  • Percuss each spinous process from T1-T12 with the hypothenar aspect of a closed fist to suggest (or detect possible) malignancy, degenerative disease or osteomyelitis
  • Malignancy
    • Post-test probability if positive: 86%
    • Specificity for malignancy: 60%
  • Osteomyelitis
    • Post-test probability if positive: 10.0% (LR+ = 2.1)
    • Post-test probability if negative: 1.2% (LR- = 0.2)

Range of Motion

  • Stand behind patient and stabilize hips or have patient sitting to eliminate lumbar spine motion
  • Forward flexion (20°-40°)
  • Extension (normal = 30°)
  • Lateral flexion (normal = 35°). Assess for motion between each vertebral segment (is it consistent or moving as a "hinge" in one area
  • Rotation (normal = 30°)

References

  1. Baxter S, ed., McScheffrey G, ed. Toronto Notes: Comprehensive Medical Reference & Review for MCCQE 1 & USMLE 2. 26th ed. Toronto: Toronto Notes for Medical Students Inc; 2010.
  2. Bickley L. Bate’s Guide to Physical Examination and History Taking. 10th ed. New York: Lippincott Williams & Wilkins; 2009.
  3. Filate W, Leung R, Ng D, Sinyor M, eds. Essentials of Clinical Examination Handbook. 5th ed. Toronto, ON. University of Toronto, 2005.
  4. Hurley K. OSCE and Clinical Skills Handbook. Halifax: Elsevier Canada; 2005.
  5. Pawa J, Lesniak, D., & Lott, A. Approach to the OSCE: The Edmonton Manual of Common Clinical Scenarios. Edmonton Manual; 2011.