MedEd OSCE, Musculoskeletal & Rheumatological

Cervical Spine Examination #1

Introduction
Patient script
Additional notes

PATIENT INFORMATION

You are a final year medical student on placement in a GP clinic. Derek is a 60- year-old pharmacist who has presented complaining of back pain post mechanical fall. Derek has no significant medical history and is not on any regular medications.

CANDIDATE INSTRUCTIONS

You will have 8 minutes to perform the following:

Perform a c-spine/neck and thoracolumbar examination (7 minutes).
Answer the examiner’s questions (1 minute).

Please note: this OSCE is to assist with learning the process/steps of a cervical and thoracolumbar spine examination. The examiner will not be providing findings.

TASK 1 – EXAMINATION (7 MINUTES)

Preliminary

Introduce yourself to the patient
Obtain consent
Wash your hands
Exposure: Above the waist is exposed
Positioning: Initially seated, then lying prone after neck examination

General inspection

Ask about patient's functional disability – getting undressed
Walking painful or difficult?
What is the posture taken?
Does the patient require assistance such as a stick or walking frame?
Any obvious deformity?
Gait
- Range of movement
- Limping
- Symmetry
- Turning
- Special Gaits
  - Trendelenburg
  - Waddling High Stepping/Foot Drag

012

Vitals

Should ask for all vital signs including
- Temperature
- HR
- BP
- RR and O2 sats

Local inspection

C-spine/neck

Muscle wasting: paraspinal, trapezius
Deformity
Swelling: spinal or paraspinal
Skin changes: erythema, scars, bruising
Scoliosis or kyphosis

Thoracolumbar

Deformity
Asymmetry
Lumbar lordosis
Scoliosis
Scars
Swelling
Bruises
On the back
- Look for gluteal wasting

Palpation

Bony landmarks: Posterior spinous processes in spine
- (C2, C6, C7, T2, T7, L4-5, S2)
Feel for
- Tenderness
- Uneven spacing of the spinous processes
Each vertebral body for tenderness and muscle spasm inthoracolumbar
Paraspinal muscles for tenderness and swelling

012

Movements

Active movements – ONLY
- C-spine
  - Flexion – touch chin to chest
  - Extension – look up and back
  - Lateral bending – touch ear to shoulder
  - Rotation – tested by getting pt to look over your shoulder
- Thoracic for twisting
  - Rotation – patient sitting on stool and asking to rotate
- Lumbar for bending
  - Flexion – touch toes with knees straight
  - Extension – lean backwards
Lateral extension – slide the right hand down right leg as far as possible

0123

Special tests

C-spine Special Tests

Spurling test
- Extend and lateral bend, push down slightly
Shoulder abduction relief test
- Do the spurling test and then lift arm and put behind head
- If pain is relieved it is positive

Thoracolumbar Special Tests

Schober's test
- Measure lumbar flexion
- Mark at posterior iliac spine on vertebral column
- Measure 10cm up and mark
- When the pt bends forward, if less than 15 cm between two marks, it is positive

Straight leg
- Patient lying down, lift the straightened leg, if sciatica suspected
- Pain is positive, if let go, pain goes away
SI joint assessment
- Lie on back – Press directly on the ASIS on each side and apply lateral pressure as to attempt to separate them
  - Pain is positive
- Lie prone – Press directly on each PSIS one at a time, checking for tenderness
- Lie on side – apply firm pressure on upper pelvic rim
  - Pain positive

TASK 2 – EXAMINER’S QUESTION (1 MINUTE)

What are the signs and symptoms of cauda equina syndrome?

Symptoms
- Back pain
- Unilateral or bilateral leg pain
- Bladder dysfunctiono disruption of bladder contraction and sensation leads to urinary retention and eventually to overflow incontinence
- Unilateral or bilateral sensory changes in legs
- Unilateral or bilateral motor weakness in legs
- Sexual dysfunction
- Bowel dysfunction

Signs
- Bilateral or unilateral lower extremity weakness
- Decreased rectal tone on voluntary contraction

Reduced or absent sensation to pinprick in the perianal region, perineum, and posterior thigh

012

Total:

Red flags for back pain

Tumor

History of cancer
Weight loss
Night pain
Age >40 or <15 years

Fracture

History of trauma
Risk factors for fragility fracture

Infection

Fever >38.0C˚
Night sweats/chills
Immunosuppression
IV drugs
Concomitant infection

Cauda equina syndrome

Urinary retention
Saddle anaesthesia
Worsening neurology – flaccid paralysis

Imaging

Routine imaging of acute back pain with no red flag symptoms or neurological deficits is uncommon and not recommended. If ongoing pain is more than 4 weeks and suspected spondylosis, spondylolisthesis and scoliosis, a plain x-ray is the modality of choice. If other differentials such as mass effect or trauma is suspected, CT spine or MRI may be indicated. MRI accessibility is limited and expensive and there are specific indications for subsidisation and often only considered if it will change management such as failure of conservative management and aim for neurosurgery.