OSCE MSK Cervical Spine

Question 1

Introduction
What steps are required in a spine examination introduction (6)?

Answer 1

1. Introduce self: Name and role
2. Confirm the patients name and age
3. Briefly explain the examination using patient friendly language
4. Gain consent & ask if the patient is in any pain at the moment
5. Adequate exposure - undressed to the waist or singlet top with neck exposed
6. Wash hands

Question 2

What order is this spine examination undertaken in (broad categories)?

Answer 2

Look, Feel, Move, Special tests

Question 3

Gait examination
What should be looked for in when examining someone’s gait?

Answer 3

Any pain/discomfort?
Any asymmetry?
Any difficulty turning around?
No foot drop (stubbed toe walk), no antalgic gait (shortened range- Limp), no evidence of pain

Question 4

General Inspection includes a visual assessment of (5)?

Answer 4

Clinical signs

1. Distress: Is the patient visibly in pain at rest or only with certain movements?
2. Posture:
   
   • Head and neck position (is there rotation of the neck to one side (torticollis).
   • Alteration of shoulder height on either side?
3. Skin changes/Scars: may provide clues regarding previous spinal surgery.
4. Wasting of muscles: suggestive of disuse atrophy secondary to joint pathology.
5. Deformity
   
   • Excess kyphotic curvature of the thoracic spine that can cause a hyperlordosis in the cervical spine

Question 5

Anterior spine inspection: What is being observed (4)?

Answer 5

1. Scars: note the location of the scar as this may provide clues as to the patient’s previous surgical history or suggest previous trauma (e.g. anterior neck scar due to anterior cervical discectomy).
2. Posture: note any asymmetry which may indicate joint pathology or scoliosis.
3. Asymmetry of the shoulder girdle: may be caused by scoliosis, arthritis, fractures or dislocation.
4. Pelvic tilt: lateral pelvic tilt can be caused by scoliosis, leg length discrepancy or hip abductor weakness.

Question 6

Lateral inspection - what is being observed (3)?

Answer 6

1. Degree of Cervical lordosis: Is normal cervical lordosis maintained?
   (hyperlordosis is associated with chronic degenerative joint disease (e.g. osteoarthritis))
2. Degree of Thoracic kyphosis: the normal amount of thoracic kyphosis is typically between 20-45º. Hyperkyphosis is associated with Scheuermann’s disease (congenital wedging of the vertebrae).
3. Degree of Lumbar lordosis: loss of normal lumbar lordosis is associated with sacroiliac joint disease (e.g. ankylosing spondylitis).

Question 7

Posterior spine inspection - what is being observed (5)?

Answer 7

1. Spinal alignment: inspect for lateral curvature of the spine indicative of scoliosis.
2. Iliac crest alignment: misalignment may indicate a leg length discrepancy or hip abductor weakness.
3. Muscle wasting/spasm: note any wasting of the paraspinal muscles which may indicate chronic spinal pathology and reduced mobility.
4. Bruising: suggestive of recent trauma or surgery.

Question 8

Feel - what structure are being felt in a spinal examination and what is being assessed?

Answer 8

Patient should lie prone

1. Palpate down the spinal processes
2. Palpate the sacroiliac joints
3. Palpate the paraspinal muscles

Question 9

What should be noted during palpation of the spine?

Answer 9

Note any tenderness, abnormalities in alignment or muscular spasms (paraspinal palpation)

Question 10

Flexion of the cervical spine:
a) Normal range?
b) Instructions?

Answer 10

a) 50°- 60°
b) Ask the patient to touch their chin to their chest

Question 11

Name the movements tested at the Cervical spine (4)

Answer 11

Flexion
Extension
Lateral flexion (L and R)
Rotation

Question 12

Extension of the cervical spine
a) Normal range?
b) Instruction?

Answer 12

a) From 0°- 50°
b) Ask the patient to look up at the ceiling.

Question 13

Lateral flexion of the cervical spine
a) Normal range?
b) Instructions?

Answer 13

a) From 0°- 45°
b) Ask the patient to touch their ear to their shoulder on each side.

Question 14

Lateral rotation of the cervical spine (from anatomical position)
a) Normal range?
b) Instructions?

Answer 14

a) 0°- 80°
b) Ask the patient to turn their head to the left and the right.

Question 15

Name the movements tested at the Lumbar spine (3)

Answer 15

Flexion of the lumbar spine

Extension of the lumbar spine

Lateral flexion of the lumbar spine

Question 16

Flexion of the lumbar spine
a) Normal range?
b) Instructions?

Answer 16

a)
b) Ask the patient to touch their toes whilst keeping their legs relatively straight

Question 17

Positioning for a cervical spine

Answer 17

Sitting on a chair for movements
Patient prone for palpation

Question 18

Completing a cervical spine examination:
What additional tests are done?

Answer 18

1. Cervical lymph node examination
2. Thyroid examination
3. Neurological examination of the upper limb
4. L and R Shoulder examination

Question 19

Name a clinical landmark in the neck helpful for palpation

Answer 19

C7/T1 spinous process
Most posterior projection, a good landmark to palpate

Question 20

When feeling a patients cervical spine, what position should they be in?

Answer 20

Patient lying prone, with their hands under their forehead
Place pillow under the chest for support

Question 21

When feeling the cervical spine and neck region, give the 5 regions that should be palpated

Answer 21

1. Spinous processes of C2-C7/T1
2. Facet joints (one thumb lateral to spinous processes)
3. Paravertebral soft tissues posteriorly (lateral to vertebrae)
4. Anterior neck muscles (for tenderness and spasm)
5. Make note of any level that is tender and clarify where it is located (midline, right or left sides)