Begin by observing the patient's posture, including the position of both neck and trunk, when entering the room.

Assess the patient for erect position of the head, smooth, coordinated neck movement, and ease of gait.

Drape or gown the patient to expose the entire back for complete inspection. If possible, the patient should be upright in the patient's natural standing position—with feet together and arms hanging at the sides. The head should be midline in the same plane as the sacrum, and the shoulders and pelvis should be level.

Neck stiffness signals arthritis, muscle strain, or other underlying pathology that should be pursued.

Lateral deviation and rotation of the head suggests torticollis, from contraction of the sternocleidomastoid muscle.

Inspect the patient from the side. Evaluate the spinal curvatures.

Inspection of the Spine

View of Patient

Focus of Inspection

From the side

Cervical, thoracic, and lumbar curves.

Cervical concavity

Thoracic convexity

Lumbar concavity

From behind

Upright spinal column (an imaginary line should fall from C7 through the gluteal cleft) Alignment of the shoulders, the iliac crests, and the skin creases below the buttocks (gluteal folds)

Cervical concavity

Thoracic convexity

Lumbar concavity

Skin markings, tags, or masses

Increased thoracic kyphosis occurs with aging. In children a correctable structural deformity should be pursued.

In scoliosis, there is lateral and rotatory curvature of the spine to bring the head back to midline. Scoliosis often becomes evident during adolescence, before symptoms appear.

Unequal shoulder heights seen in Sprengel's deformity of the scapula (from the attachment of an extra bone or band between the upper scapula and C7); in "winging" of the scapula (from loss of innervation of the serratus anterior muscle by the long thoracic nerve), and in contralateral weakness of the trapezius.

Unequal heights of the iliac crests, or pelvic tilt, suggest unequal lengths of the legs and disappear when a block is placed under the short leg and foot. Scoliosis and hip abduction or adduction may also cause a pelvic tilt. "Listing" of the trunk to one side is seen with a herniated lumbar disc.

Birthmarks, port-wine stains, hairy patches, and lipomas often overlie bony defects such as spina bifida.

Cafe-au-lait spots (discolored patches of skin), skin tags, and fibrous tumors in neurofibromatosis

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