Knowledge · Clinical Examination

Spine and Neurological Examination: Movement, Root Signs and Cauda Equina

By Dr Richard Miller, MBChB FRCS with the MRCS Part B Questions Team · Reviewed 15 September 2026

In brief

Examine the spine by region with look, feel and move, then screen the limbs neurologically; a straight leg raise is positive when pain is reproduced below 60 degrees, and cauda equina symptoms need emergency referral for MRI.

Examine the spine from the front, side and behind, palpate each vertebral level, then test movement region by region before screening the limbs neurologically. NICE Clinical Knowledge Summaries call a straight leg raise positive when pain is reproduced below 60 degrees of hip flexion, and cauda equina symptoms need emergency referral, not observation.

Key takeaways

NICE CKS asks you to observe the spine for deformity and abnormal curvature, palpate for tenderness, and watch gait.
Pain on flexion radiating to the leg suggests disc herniation with nerve root impingement; pain on extension suggests facet arthropathy or spinal stenosis, according to NICE CKS.
A straight leg raise is positive when pain is reproduced below 60 degrees of hip flexion on the same side.
The femoral stretch test, performed prone, assesses upper lumbar disc herniation.
The national suspected cauda equina pathway states that a digital rectal examination is not necessary, but subjective perianal sensation should be recorded.

What is the examiner marking at the spine station?

The Intercollegiate blueprint marks a physical examination station out of 20 across four domains: clinical and technical skill carries 8 marks, and clinical knowledge and its application, communication and professionalism carry 4 marks each. The station also gets a separate global rating of pass, borderline or fail.

More than half the marks therefore sit outside your knowledge of the condition, so a silent but technically correct examination scores poorly. You are signalled at six minutes of the nine to present your findings, so the sequence has to finish inside six.

The examiner is marking a regional, systematic examination and, above all, whether you actively screen for cauda equina syndrome. A missed red flag fails the station whatever else you do.

Say the red flags out loud as you ask about them, so the examiner hears the safety netting.

How should you start the spine examination?

Introduce yourself, gain consent, expose the back and legs adequately and ask about pain before you touch.

Then watch the patient stand and walk. NICE CKS notes that a high-stepping gait with an inability to lift the foot suggests weakness of ankle dorsiflexion.

What am I looking for on inspection of the spine?

Look from the front, the side and behind for deformity and abnormal curvatures, as NICE CKS directs.

Skin, for scars, midline hair patches, pigmentation and sinuses
Muscle asymmetry and paraspinal wasting
Curvature, comparing thoracic kyphosis and lumbar lordosis with the normal
Scoliosis, which becomes more obvious on forward flexion

**Scoliosis** is a lateral curvature of the spine away from the midline, and it is described by the side and level of the convexity.

What should you palpate?

Palpate each spinous process in turn and the paraspinal muscles, then the sacroiliac joints, localising tenderness and feeling for a step between adjacent vertebrae.

NICE CKS lists a structural step between vertebrae and point tenderness over a vertebral body among the features that raise concern about spinal fracture.

Which movements should you test, by region?

Test active movement first, then passive where appropriate, region by region so nothing is missed.

Cervical flexion, extension, lateral flexion and rotation
Thoracic rotation, with the pelvis anchored by your hands
Lumbar flexion and extension, and lateral flexion with the hand sliding down the leg
Schober's test, which measures lumbar flexion, named here without a measurement because the legacy figures could not be verified

Interpret what you find. NICE CKS states that pain on flexion radiating to the leg suggests disc herniation impinging on a nerve root, while pain on extension can suggest facet arthropathy or spinal stenosis.

Which special tests identify nerve root irritation?

The straight leg raise and the femoral stretch test, both described by NICE CKS.

Straight leg raise, with the patient supine and the knee extended, flexing the hip gradually; positive when pain is reproduced below 60 degrees on the same side
Femoral stretch test, with the patient prone, flexing the knee and extending the leg; positive when it reproduces the leg pain, and used for upper lumbar disc herniation
Extensor plantar response, positive when the toes extend and fan on stimulating the lateral sole, which may indicate an upper motor neurone lesion

How do you screen for cauda equina syndrome?

Ask directly about the red flag symptoms and record the answers. The GIRFT and NHS England national pathway warns that cauda equina syndrome has no set clinical pattern, that no single symptom or combination has good diagnostic accuracy, and that negative physical tests do not rule it out when symptoms are present.

Difficulty initiating micturition or impaired sensation of urinary flow
Altered perianal, perineal or genital sensation in the S2 to S5 dermatomes
Severe or progressive neurological deficit of both legs, such as major weakness of knee extension, ankle eversion or foot dorsiflexion
Loss of sensation of rectal fullness
Sexual dysfunction, including loss of genital sensation

The pathway asks for emergency referral to the nearest hospital with emergency MRI when these symptoms started or deteriorated within the last 14 days, and says an emergency MRI should be done within four hours of request.

What are the most common mistakes at this station?

Examining the back and never testing the legs neurologically
Performing a digital rectal examination reflexively, when the national pathway says it is not necessary and asks for subjective perianal sensation to be recorded instead
Treating a negative straight leg raise as reassurance in a patient reporting cauda equina symptoms
Forgetting the hips, which NICE CKS asks you to examine because hip pathology mimics referred leg pain
Missing the fracture, cancer and infection red flags that NICE CKS lists alongside cauda equina

How should you finish the spine examination?

Complete a lower limb neurological examination, assess gait, and summarise with your red flag status stated explicitly.

NICE CKS defines new significant motor loss as weakness below MRC grade 3, meaning the patient cannot move the examined foot or leg against resistance or gravity, which is a red flag in its own right.

The MRCS Part B Questions bank has a spine examination station at /Sample-Questions.

Key evidence

Sciatica (lumbar radiculopathy): assessment — NICE Clinical Knowledge Summaries (2026)
Sciatica: red flag symptoms and signs — NICE Clinical Knowledge Summaries (2026)
National Suspected Cauda Equina Pathway, March 2026 — Getting It Right First Time and NHS England (2026)

FAQ

What counts as a positive straight leg raise?

NICE CKS states the test is positive if pain is reproduced below 60 degrees of hip flexion on the ipsilateral side, with the patient supine and the knee extended. Pain in a sciatic distribution supports nerve root irritation. Back pain alone on the manoeuvre is not the same finding.

When is a femoral stretch test used?

For upper lumbar disc herniation. NICE CKS describes it with the patient prone, flexing the knee and extending the leg, and calls it positive when the leg pain is reproduced. Use it when symptoms are in the anterior thigh rather than below the knee.

Do I need to do a per rectum examination for suspected cauda equina?

The GIRFT and NHS England national suspected cauda equina pathway states that a digital rectal examination is not necessary, but subjective perianal sensation should be recorded. This is a change from older teaching. Record what the patient reports and refer without delay.

How quickly should a suspected cauda equina patient be scanned?

The national pathway says MRI at the presenting hospital is best practice in and out of hours, and that an emergency MRI for suspected cauda equina should be undertaken as soon as possible and certainly within four hours of the request to radiology. Referral is emergency when symptoms started or deteriorated within 14 days.

Can MRI alone diagnose cauda equina syndrome?

No. The national pathway states plainly that cauda equina syndrome is a collection of symptoms and clinical signs, and that an MRI scan on its own cannot diagnose it. The scan confirms a compressive lesion; the diagnosis is clinical.

Why is Schober's test described without numbers here?

Because the measurement on the legacy page reversed the usual marks and no primary source could be fetched on 15 September 2026 to confirm either version. The test is named as a measure of lumbar flexion only. Quote a figure in the exam only if you can source it.

The MRCS Part B Questions Team

Written and maintained by doctors who have sat and scored well at this interview, and reviewed against the current published guideline in each case. Guidance changes — check the source before you rely on a threshold.

Last reviewed 15 September 2026

More in Clinical Examination

Abdominal Examination for MRCS Part B: Inspection, Palpation and the Organs

Examine the abdomen flat with one pillow, exposed from nipples to knees in practice covered to the groin: inspect, palpate lightly then deeply, examine liver, spleen and kidneys, percuss for ascites and auscultate.

Breast Examination for MRCS Part B: Positions, Quadrants and Triple Assessment

Inspect the breasts in four positions, palpate the normal side first through all four quadrants and the axillary tail, examine the nipple and the regional nodes, then offer the components of triple assessment.

Cardiovascular Examination for MRCS Part B: Sequence, Signs and Presentation

Examine the cardiovascular system in a fixed order: end of the bed, hands, pulse, blood pressure, JVP, face, praecordium, then auscultation in four areas with a finger on the carotid, finishing with peripheral pulses and oedema.

Cranial Nerve Examination for MRCS Part B: Twelve Nerves in Order

Test the cranial nerves in numerical order: smell, vision and pupils, eye movements, facial sensation and the muscles of mastication, facial movement, hearing, palate and gag, accessory muscles and the tongue.

Practise this at exam level

The question bank turns this topic into station-style questions with model answers and AI-marked spoken practice.

Explore the question bank