1. For the Primary Care clinician
Low Back Pain: Focused Exam
For the Primary Care clinician

2. 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

3. Today’s talk
Focus on practical information to help the practitioner know:
what questions to ask,
what exam to perform,
what studies to order.

4. Today’s talk 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

5. Anatomy review 7 Cervical vertebrae 12 Thoracic vertebrae
5 Lumbar vertebrae
Sacrum (5 fused)
Coccyx (4 fused)
Focus today on lumbar/sacral spine

6. Anatomy review Vertebra Intervertebral discs Facet joints Spinal nerve
Epidural space

7. Anatomy review

8. Pain generators Disc rupture Nerve impingement Joints-facets or SI
Myofascial

9. 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

10. 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.

11. Examination for Radicular pain
Neurologic exam:
Strength
Reflexes
Sensation
Provocative tests:
Straight leg raise (SLR), contralateral SLR, Slump test

12. 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.

13. Neuro Exam-Strength
Hip Flexor Strength Testing
L1,2,3

14. Neuro Exam-Strength
Knee Extension
L2-4
Buttock should rise from table

15. Neuro Exam-Strength
Dorsiflexion
L4,5

16. Neuro Exam-Strength Extensor Hallucis Longus (EHL)
Big toe dorsiflexion L5

17. Neuro Exam
Plantar Flexion
One-legged x 3 = 5/5 strength S1

18. Neuro Exam-reflexes
Patella Reflex L4

19. Neuro Exam-reflexes
Medial Hamstring Reflex L5

20. Neuro Exam-reflexes
Achilles Reflex S1

21. Neuro Exam-Sensation
Pinprick Sensation Testing L2

22. Neuro Exam-Sensation
Pinprick Sensation Testing L3

23. Neuro Exam-Sensation
Pinprick Sensation Testing L4

24. Neuro Exam-Sensation
Pinprick Sensation Testing L5

25. Neuro Exam-Sensation
Pinprick Sensation Testing S1

26. Neuro Exam-Sensation
Pinprick Sensation Testing S2

27. Provocative testing
SLR
cSLR
30-70 degrees

28. 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.

29. Disc disease May see disc space narrowing on plain films.
May see disc extrusion, bulges on MRI

30. Degenerative joint disease
Facet joints, or sacroiliac joint may be affected
You may see facet degeneration, spurring, and/or osteophyte formation on radiographic studies.

31. Combined Extension & Rotation
Reproduction of Pain

32. 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.

33. Exam

34. Alignment
Weight Bearing Joints
If unable to determine free standing – try having patient stand against a wall

35. Offset
Rotation
hand position
shoulder position

36. Weight Balance

37. Exam
Shoulder Height
symmetric

38. Exam
Iliac Crest Height
symmetric

39. Adam’s Forward Bending Test
Scoliosis
Fingertip to Floor
ROM
Reproduction of Pain

40. Extension
ROM
Reproduction of Pain

41. 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. Spine. 5:117-25, 1980.