OnExam

Inspection

  • Inspect patient in standing and sitting, anteriorly, posteriorly and laterally
    • Gait
    • Posture and stance
    • Muscle atrophy, spasm or increased tone
    • Gluteal fold symmetry
    • Iliac crest symmetry
    • Approximate comparative leg length
    • Lordotic lumbosacral curvature (excessive lordosis, flattening)
    • Thoracic spine and hips for causes of lumbar spine issues

Palpation

  • While patient standing note areas of pain, swelling, spasm, atrophy, deformity or crepitus in the following structures:
    • Each lumbar spinous process
      • Tenderness: fracture, infection, arthritis
      • Step-offs: spondylolisthesis
    • Facet joints deep in paraspinal muscles
    • Paraspinal muscles
    • Iliac crests
    • Each sacroiliac (SI) joint at posterior superior iliac spine (PSIS) note symmetry
    • Sciatic nerve
      • Midway between ischial tuberosity and greater trochanter of femur
      • Often best examined with patient lying on side and hips flexed
    • Thoracic spine
    • Hips

Percussion

  • Percuss each spinous process from L1-L5 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

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.