Back Examination

Back Pain Examination the Proper Way

Medical Examination of Low Acute Back Pain

Differential Diagnosis of Low Back Pain:

acute mechanical low back pain (85%)
neoplastic
neurologic (cauda equina syndrome disc herniation)
fracture
infectious (osteomyelitis, TB Pott’s disease)
inflammatory (seronegative spondylarthropathies – consider if patient a young male)
metabolic (osteorporosis, )
referred (prostatitis, pyelonephritis, pancreatitis, abdominal aortic aneurysm, cholelithiasis)

Disc Generated Back Pain
Back Dominant Pain with PAIN IN THE BACK, buttock, trochanter, and groin.
Constant or intermittent. WORSE WITH FLEXION. NORMAL NEUROLOGICAL examination. Better with extension, then a fast responder. No change or worse with extension, slow responder.

90% of problems are from disc herniation at L5 or S1

Facet Joint Back Pain
Back Dominant Pain with PAIN IN THE BACK, buttock, trochanter and groin. INTERMITTENT PAIN. WORSE WITH EXTENSION. NORMAL NEUROLOGICAL examination.

Sciatica
Leg dominant pain. PAIN BELOW THE BUTTOCKS IN THE SHINS AND KNEES. CONSTANT. Aggravated leg pain with movement and position of back. Any spinal movement while make the pain worse. MUST HAVE NEUROLOGICAL FINDINGS AND OR CONDUCTIVE LOSS.

Neurogenic Claudication
This occurs when there is no blood going to the nerves of the spinal cord. Leg dominant pain. PAIN BELOW BUTTOCKS, BUT FOR A SHORT DURATION. INTERMITTENT. SYMPTOMS WORSE WITH ACTIVITY. BETTER WITH REST AND FLEXION (does not compress vessels as you open the intervertebral foramen which gives more room for the nerve). NORMAL NEUROLOGICAL examination, but may have some conductive loss. RULE OUT WITH BETTER ON FLEXION.

Medical History for Back Pain:

Identifying Data – name, age, married, employment, support at home
OPPQRS…
E.g. Location - worse in back (mechanical back pain) or leg (sciatica, if shooting) Palliative and provocative factors, progression, previous instances

PROVOKING FACTORS:
worse with flexion or extension
constant or intermittent

Review of Systems
Associated Symptoms:
constitutional (fatigue, sleep, fever, chills, night sweats, appetite, weight loss)
timing (duration, frequency, progression)
triggering event (fall, lifting, etc)

Back Pain Red Flags

B – bowel incontinence, bladder retention (new)
A – anestheis saddle, numbness, tingling, weakness
C- cancer history – ask about systemic symptoms such as weight loss, appetite, fatigue
C – cracked bone, fracture, trauma history
K – chronic, osteoporosis, has it happened before?
P – paresthesia (tingling in legs)
A – age greater than 50
I – infections, intravenous drug use, urinary tract infections, tuberculosis (bone infection, osteomyelitis, Pott’s); inflammation (seronegative spondyloarthropathies)
N – night pain (neoplastic)

Inflammatory Back Pain

History
Joints involved – ankles, hands mainly
Total number of joints involved
Pain at rest
Pain relived with exercise
Morning stiffness greater than 1 hour
Sleep disturbances
ROM range of motion limitations

Activities of Daily Living Changes

Gross Motor – walking, stairs
Fine Motor – dressing, grooming, eating, hand grip

Other systems involved
Extra-articular features

New rashes
Eye irritation
Dry mouth
Chest pain
Paresthesia
Numbness
Neurological symptoms

Past Medical History:

any serious illnesses in the past?
previous instances and how managed
recent infections (urinary tract infections, intravenous drug use)
osteoporosis (fracture)
immunosuppression (hiv, post-transplant)
autoimmune diseases (seronegative spondylarthropathies)
malignancy

medications and allergies
smoking, alcohol, intravenous drug use

Family History
arthritis
malignancy

Social History
impact on life
employment and occupation
activity limitations
coping

Back Pain Physical Examination:

Observe body position, contour (bony aligment – kyphosis, scoliosis), inspect shoulder and hip heights by looking at iliac crests and scapulas (shoulder blades), there should be not asymmetry and gait of patient
Inspect for:

masses, scars, lesions
atrophy (>2 cm circumference between limbs means problem), hypertrophy
muscle bulk and symmetry
signs of inflammation: erythema, swelling, warmth, pain, deformity
signs of trauma

Palpation
palpation (spinous processes for deformity, tenderness (fracture), alignment, paravertebral muscles spasm)
palpate associated soft tissue for tenderness
palpate for vertebral step offs – spondyloarthropathy
percussion (tenderness over spinous processes)

Range of Motion (ROM)
Flexion – touch your toes
Extension – bend over backwards
Lateral flexion – palms on hips, run hands down sides
Rotation – twist with hands on hips
Chest expansion – ask patient to take a deep breath, ask if any discomfort with, and measure chest expansion, normal should be greater than 5 cm
Walk - ask patient to walk, and observe gait

Special Tests:
Muscle Strength Tests
Squat L4, Heel Walk L5, Tip-toe walk S1
Reflexes
Knee jerk L4, Ankle jerk S1
Babinski response – UMN lesion

Sensory Tests
Light touch on the foot to test sensation
Medial foot for L4, dorsal for L5, and lateral foot for S1
Light touch midline of buttocks to test for saddle anesthesia (red flag)
DRE – digital rectal examination, for anal reflex, S1, S2
If they have incontinence, they will have S2-S4 problem

Tests for Sciatic tension
Test for nerve root irritation, tension
Signifies a L5, S1 problem, nerve radiculopathy
Passively raise leg, keeping it straight
If pain at 70 degrees of leg raise, worse with ankle dorsiflexion or internal rotation of leg and relived by ankle plantar flexion, external rotation of leg, suggests L5, S1 problems – radiculopathy.
PAIN MUST BE IN LEG THOUGH. IF IN BACK, NOT SCIATICA
Compare with other leg.

Femoral Stretch Test
For sciatica also
Patient lying prone, stretch femoral nerve roots (L2-L4) by extending the hip, lifting the thigh with one hand and using the other hand to maintain full extension of the knee. Pain radiating into the thigh suggests nerve root irritation (femoral nerve root irritation).

inspection (symmetry, bony abnormalities, shoulder and hip heights, trauma, scars)
gait (normal walk, heel walk(l4,l5), toe walk (s1,s2)) + notes difficulty getting up from seat
rom (flexion, extension, lateral flexion, rotation)
neuro screen
motor : walks on heels, toes, + squat and stand up
sensory (medial calf – l4, 1st web space – l5, lateral foot – s1)
reflex (knee jerk – l3,l4, ankle jerk – s1,s2) – do both sides.
special tests
straight leg raise (sciatica)
femoral stretch test (femoral nerve root irritation)

Investigations and lab tests

no x-rays unless red flags
no lab tests unless red flags

Management

reassurance – 90% much improved by 4 weeks
ice/heat
early gradual return to activity
rest < 4 days as needed
exercises + stretching
proper lifting technique
pharmacologic
nsaids
acetaminophen
chiropractic may be beneficial in some
work modifications
lumbar corset