Back Exam

Back Exam

General

  • Wash your hands upon entering the room
  • Introduce yourself and the exam to the patient in a way that the patient will understand
  • Patient should be standing for the initial part of the exam, but will need to sit and lie down for certain elements
  • Drape the patient so their back is exposed. For female patients, ensure their chest remains draped throughout the exam

Vital Signs

Vital signs should be measured on every patient. They include:

  • Blood pressure
  • Heart rate
  • Respiratory rate
  • Temperature
  • Oxygen saturation may also be included

Inspection

Begin the back exam by having the patient stand in front of you. You should be inspecting for the following things:

  • Patient's general appearance
    • Are they unable to stand up/using supports to stand
    • Do they look to be in pain
    • Is their trunk flexed
  • Contour
    • Signs of kyphosis, scoliosis
    • Scoliosis may become more apparent when the patient bends over. It will appear as a hump in the thorax.
  • Color
    • Signs of inflammation (erythema)
  • Masses, scars, lesions
    • Bony abnormalities, scars from trauma or surgery
  • Gait
    • Ask the patient to walk to the end of the room and back
    • Examine for any gait abnormalities, specifically an antalgic gait, or a trendelenburg gait (hip abductor weakness)
  • Trendelenburg Test (L5 nerve root)
    • Stand behind the patiet and place your hands on the patient's iliac crests
    • Ask the patient to stand on one leg
      • Normal - the iliac crests remain level
      • Abnormal - a drop in the non weight-bearing hip. This suggests weakness in the hip abductors of the weight bearing hip.
    • Repeat the above for the other leg

Palpation

Palpation the back involves three components

  • General palpation
    • Palpate down the spine for evidence of tenderness or any gross deformities
    • Has little utility
  • Chest expansion (For inflammatory spinal conditions)
    • Wrap a tape measure around the patients chest at the level of the xiphoid process
    • Ask the patient to take a deep breath and fully exhale. This is the starting position. Pull the tape measure tight. Note this measurement.
    • Ask the patient to fully inhale. Let out the tape as the patient inhales. Note this measurement
    • The difference in the tape measure between expiration and inspiration is the chest expansion.
  • Schober Test (For inflammatory spinal conditions)
    • This test is only of value in younger individuals. It can produce false negatives in individuals over 40 years
    • Ask the patient to stand with normal posture
    • Make a mark midway between the two posterior superior iliac spines
    • Measure 10cm above this point and make another mark
    • Ask the patient to bend foward
    • Remeasure the distance between the two marks
      • Normal - distance between the marks increases by 5cm
      • Abnormal - distance between the marks increases by less than 5cm. Suggests ankylosing spondylitis or another seronegative condition

Neurological Screen

The neurological screen tests for functioning of reflexes, and the motor and sensory systems

  • Motor Screen
    • Trendelenburg test - hip abduction (L5)
      • See Trendelenburg test in Inspection section above
    • Extensor Hallucis Longus (L5) - Large toe extension
      • Ask patient to extend their big toe and apply resistance
    • Ankle Dorsiflexion (L5)
      • Ask the patient to elevate their foot against resistance
    • Ankle Plantarflexion (S1)
      • Ask the patient to depress their foot against resistance (Ask them to press on the gas)
    • Flexor Hallucis Longus (S1) - Large toe flexion
      • Ask the patient to flex their big toe against resistance
    • Gluteus Maximus Tone (S1)
      • Ask the patient to tense their buttock as you palpate for tone
  • Sensory Screen
    • Saddle Sensation (S2, S3, S4)
      • Palpate lightly between the upper buttock either when the patient is standing or when prone
    • Peripheral Sensation
      • Assess the peripheral nerve roots for sensation
      • Generally only if suggested by the history
      • See the sensory exam for details
  • Reflexes
    • Ankle Reflex (S1)
      • Can be assessed with the patient kneeling on a chair, or while sitting
      • Strike the reflex hammer against the calcaneal tendon
    • Knee Jerk Reflex (L3, L4)
      • Assess with the patient sitting
      • Strike the reflex hammer against the patellar tendon
    • Plantar Response (Babinski)
      • Warn the patient before performing this manoeuver
      • Run a blunt object up the lateral edge of the foot
        • Normal - toes flex
        • Abnormal - toes splay suggesting an upper motor neuron lesion

 Figure 1: The Plantar Response A - Normal, B - Abnormal

Figure 1: The Plantar Response A - Normal, B - Abnormal

Special Tests

 There are two special tests for nerve root irritation:

  • Straight Leg Raise
    • Ask the patient to lie supine with the affected leg extended. Ask the patient to flex the contralateral leg
    • Gradually lift the patient's leg
      • Positive test - Reproduction of typical leg pain at any level of elevation
      • Back or buttock pain is not significant
  • Femoral Stretch Test - If suggested by the history
    • Ask the patient to lie prone with the affected leg extended
    • Gradually left the affected leg
      • Positive test - Reproduction of typical anterior thigh pain
      • Back pain is not significant

Four Patterns of Back Pain

Using information from the history and physical exam, one can categorize back pain into one of four syndromes. They are as follows:

  • Pattern 1
    • History
      • Back dominant pain (felt most intensely in or over the back, buttock, coccyx, greater trochanters, or groin)
      • Pain increases with back flexion
      • Pain may be constant or intermittent
    • Physical Examination
      • Back dominant pain (location of pain matches description from the history)
      • Pain increases with back flexion
      • Neurological exam is normal or non-contributory
  • Pattern 2
    • History
      • Back dominant pain
      • Pain increases with back extension, never with back flexion
      • Pain is always intermittant
    • Physical Examination
      • Back dominant pain (location of pain matches description from the history)
      • Pain increases with back extension, unchanged or reduced with back flexion
      • Neurological exam is normal or non-contributory
  • Pattern 3
    • History
      • Leg dominant pain
      • Pain is affected by back movement or position
      • Pain is constant
    • Physical Examination
      • Leg dominant pain (location of pain matches description from the history)
      • Pain is affected by back movement or position
      • Always positive neurological findings (positive irritative test and/or a conduction loss)
  • Pattern 4
    • History
      • Leg dominant pain
      • Pain is increased with activity in extension, relieved by rest in flexion
      • Pain is intermittent
    • Physical Examination
      • Irritative tests are negative (straight leg raise/femoral stretch tests)
      • May be a conduction loss

Adapted from the ASCM1 Student Guide by Dr. Hamilton Hall and Dr. Jean Hudson