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Spine OSCE Examination Quiz

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You have just finished examining the lumbar spine of a 42-year-old woman with severe lower back pain radiating into both legs. She now reports new difficulty passing urine and numbness around the perineum. What is the most appropriate way to complete the examination and immediate assessment?

Perform a full neurological examination of the legs, check perianal sensation and anal tone, and arrange an urgent MRI scan of the spine. Perform a full neurological examination of the legs, check perianal sensation and anal tone, and arrange an urgent MRI scan of the pelvis. Ask her to empty her bladder, perform a bladder scan for post-void residual volume, and arrange a same-day ultrasound of the renal tract. Perform a full neurological examination of the legs, check perianal sensation and anal tone, and arrange an urgent CT scan of the lumbar spine. Send a urine sample for culture, request blood inflammatory markers, and arrange an outpatient neurological review.

A Perform a full neurological examination of the legs, check perianal sensation and anal tone, and arrange an urgent MRI scan of the spine. ✓
B Perform a full neurological examination of the legs, check perianal sensation and anal tone, and arrange an urgent MRI scan of the pelvis.
C Ask her to empty her bladder, perform a bladder scan for post-void residual volume, and arrange a same-day ultrasound of the renal tract.
D Perform a full neurological examination of the legs, check perianal sensation and anal tone, and arrange an urgent CT scan of the lumbar spine.
E Send a urine sample for culture, request blood inflammatory markers, and arrange an outpatient neurological review.

The answer is A: Perform a full neurological examination of the legs, check perianal sensation and anal tone, and arrange an urgent MRI scan of the spine.

Explanation

Why A is correct

See Introduction. Option A is correct. Difficulty passing urine and numbness around the perineum (the area between the genitals and the anus, often called the saddle area) in a patient with severe back pain and pain in both legs are red flags for cauda equina syndrome: compression of the bundle of nerve roots at the lower end of the spinal canal that supplies the legs, bladder, bowel and saddle area. Completing the examination here means a full neurological examination of the legs, checking perianal sensation and anal tone (a digital rectal examination, with the patient's consent) and arranging an urgent MRI scan of the spine. Current UK national guidance states that symptoms alone are enough to justify an urgent same-day MRI, and a rectal examination is not needed in primary care before requesting it. Saddle numbness is often partial rather than complete, so ask about sensation carefully. A plain-language aid: new bladder trouble plus saddle numbness with back pain means emergency MRI.

Red flags: New difficulty passing urine and saddle numbness with severe back pain and pain in both legs.
Likely diagnosis: Cauda equina syndrome, compression of the nerve roots at the lower end of the spinal canal.
Complete the examination: Full neurological examination of the legs, with perianal sensation and anal tone.
Next step: An urgent same-day MRI scan of the spine.

Why the other options are incorrect

B. Perform a full neurological examination of the legs, check perianal sensation and anal tone, and arrange an urgent MRI scan of the pelvis.: Pelvic MRI may show local pelvic disease, but the red-flag combination localises to the cauda equina within the lumbar spine, so an MRI of the wrong region would miss the compressing lesion.
C. Ask her to empty her bladder, perform a bladder scan for post-void residual volume, and arrange a same-day ultrasound of the renal tract.: A bladder scan and renal tract ultrasound may identify urinary retention or obstruction, but they do not assess the spinal nerve roots and would delay the urgent MRI she needs.
D. Perform a full neurological examination of the legs, check perianal sensation and anal tone, and arrange an urgent CT scan of the lumbar spine.: CT of the lumbar spine is not the first-line test for cauda equina syndrome because it shows soft tissue compression poorly; urgent MRI is the standard, with CT reserved for cases where MRI cannot be used.
E. Send a urine sample for culture, request blood inflammatory markers, and arrange an outpatient neurological review.: Urine culture and blood inflammatory markers may be adjuncts, but an outpatient neurological review is not urgent enough for suspected cauda equina syndrome, where same-day imaging is required.

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More questions from this set. Start the quiz to answer them and see each explanation.

1
You are examining a patient with suspected nerve-root pain from an upper lumbar disc prolapse. Which description best identifies a positive femoral nerve stretch test?
2
A woman with back and leg symptoms is asked to walk a short distance, turn and walk back. Each time she puts weight on her left leg, her pelvis drops to the right. What best explains this?

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