Low Back Pain: Focused Exam
For the Primary Care clinician
Low Back Pain
• Common complaint in primary care, yet:
– Often difficult complaint to address when
dealing with a complicated patient
– Providers may be unsure of exam
– Seen as chronic problem that does not
improve, and may be concerned about
medication- or disability-seeking patients
Today’s talk
• Focus on practical information to help the
practitioner know:
• what questions to ask,
• what exam to perform,
• what studies to order.
Today’s talk
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Anatomy review
Pain generators of the back
Exam to rule out emergent issues
Exam for radiculopathy
Exam to discover cause of patient’s pain
Appropriate ordering of studies
Anatomy review
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7 Cervical vertebrae
12 Thoracic vertebrae
5 Lumbar vertebrae
Sacrum (5 fused)
Coccyx (4 fused)
• Focus today on
lumbar/sacral spine
Anatomy review
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Vertebra
Intervertebral discs
Facet joints
Spinal nerve
Epidural space
Anatomy review
Pain generators
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Disc rupture
Nerve impingement
Joints-facets or SI
Myofascial
Emergent causes of back pain
• Cancer
– Ask: 1) history of cancer; 2) pain which wakes patient
from sleep, 3) weight loss, 4) new onset of pain in an
elderly patient,
• Cauda equina
– Ask: 1) bowel or bladder problems such as retention,
incontinence, decreased sensation; 2) saddle
numbness.
• Infection
– Ask: 1) fevers, 2) history of epidurals or IVDU
Examination for Radicular pain
• Mostly caused by intervertebral disc
problems such as herniation, degenerative
disc disease, or narrowing from
degenerative joint disease.
• Looking for a pattern of neurologic deficits:
for example, that L5 strength, reflexes and
sensation are all affected.
Examination for Radicular pain
• Neurologic exam:
– Strength
– Reflexes
– Sensation
• Provocative tests:
– Straight leg raise (SLR), contralateral SLR,
Slump test
Strength testing
• Explain to patient that you are testing her
strength and would like her to push as
hard as possible; difference between true
weakness and pain-inhibited weakness.
• In general, you should not be able to
“break” the person’s strength; if you can,
there may be weakness. Test against
strength of non-affected side, if possible.
Neuro Exam-Strength
• Hip Flexor Strength
Testing
– L1,2,3
Neuro Exam-Strength
• Knee Extension
– L2-4
– Buttock should rise
from table
Neuro Exam-Strength
• Dorsiflexion
– L4,5
Neuro Exam-Strength
• Extensor Hallucis
Longus (EHL)
– Big toe dorsiflexion
– L5
Neuro Exam
• Plantar Flexion
– One-legged x 3 = 5/5
strength
– S1
Neuro Exam-reflexes
• Patella Reflex
– L4
Neuro Exam-reflexes
• Medial Hamstring
Reflex
– L5
Neuro Exam-reflexes
• Achilles Reflex
– S1
Neuro Exam-Sensation
• Pinprick Sensation
Testing
– L2
Neuro Exam-Sensation
• Pinprick Sensation
Testing
– L3
Neuro Exam-Sensation
• Pinprick Sensation
Testing
– L4
Neuro Exam-Sensation
• Pinprick Sensation
Testing
– L5
Neuro Exam-Sensation
• Pinprick Sensation
Testing
– S1
Neuro Exam-Sensation
• Pinprick Sensation
Testing
– S2
Provocative testing
• SLR
• cSLR
• 30-70 degrees
Radicular Pain
• If your neurologic exam shows concern for
acute neurologic changes in a nerve root
pattern, consider MRI and referral to
orthopedic surgeons.
• If you are unclear about the cause of
neurologic changes, such as radiculopathy
versus diabetic neuropathy, consider
referral for EMG.
Disc disease
• May see disc space
narrowing on plain
films.
• May see disc
extrusion, bulges on
MRI
Degenerative joint disease
• Facet joints, or
sacroiliac joint may be
affected
• You may see facet
degeneration,
spurring, and/or
osteophyte formation
on radiographic
studies.
• Combined Extension
& Rotation
– Reproduction of Pain
Myofascial pain
• May see muscle spasm, tense, tight
muscles.
• Patient may get relief from NSAIDs,
acetaminophen, topical preparations,
stretching, trigger point injection.
• May be a component of pain, no matter
the root cause of pain.
Exam
• Alignment
• Weight Bearing Joints
• If unable to determine
free standing – try
having patient stand
against a wall
• Offset
• Rotation
– hand position
– shoulder position
• Weight Balance
Exam
• Shoulder Height
– symmetric
Exam
• Iliac Crest Height
– symmetric
• Adam’s Forward
Bending Test
– Scoliosis
• Fingertip to Floor
– ROM
• Reproduction of Pain
• Extension
– ROM
• Reproduction of Pain
Waddell test
• Tests of malingering
• Each test counts as +1 if +, 0 if – Superficial skin tenderness to light pinch over wide area of
lumbar spine
– Deep tenderness over wide area, often extending to thoracic
spine, sacrum, and/or pelvis.
– Low back pain on axial loading of spine in standing
– SLR test positive supine, but not when seated with knee
extended to test babinski reflex.
– Abnormal or inconsistent neurological (motor and/or sensory)
patterns.
– Overreaction.
– If 3+ points or more, investigate for non-organic cause.
Waddell, GJ et al. Nonorganic
physical signs in low back pain.