Back Pain HX & Examination

History

1. The course of pain.
2. Is there evidence of a systemic disease?
3. Is there evidence of neurologic problems?
4. Occupational history.
5. Risk factors.
6. Red flags.
7. Yellow flags.

• Circumstances associated with pain onset.
• Factors altering pain (stiffness at rest or at night, decrease with movement)
• Is pain present continuously or on & off?
• Effect of pain on activities.
• Effect of pain on sleep.

---

Back Pain Examination

1. Inspection of back and posture
2. Palpation/Percussion of spine
3. Range of motion
4. Neurologic examination
5. Straight Leg Raising (SLR)

General Examination Principles

• Permission
• Explain
• Privacy

Vital Signs

• Patient should be standing with the whole trunk exposed.

Examination Steps

• Look ➔
• Feel ➔
• Movement ➔
• Neurologic Al tests

Inspection

• Gait

• Posture

  • head/shoulders, — listing, flexion/extension, pelvic tilt

• Muscle balance, - Habitus

• Alignment

Palpation and Percussion

• Bone

  • tenderness or deformity -
    • over spinous processes

• Joints

  • facet and sacroiliac joint -
    • tenderness

• Muscles

  • paraspinal tension and -
    • trigger points

Range of Motion

• Often very limited globally -
• Secondary to pain
• Perform slowly with physical -
  support

Flexion (normal = 90 degrees)

Lateral Bending

• (normal = 45 degrees, hand to knee)

Rotation

• (normal = 90 degrees, stabilize hips)

Extension

• (normal = 30 degrees)
  • narrows canal, loads facet joints

Straight Leg Raising (SLR)OSPE

• Raise the patient’s extended leg with the ankle dorsiflexed.

• Normally 80 – 90 degrees no pain

• It will be limited by sciatica pain in lumbar disc prolapse. (<70 ) → (exactly from 30 to 70)

Neurologic Testing

• We should focus on the L5 and S1 nerve roots
• 98% of disc herniation occurs at L4-5 and L5-S1
• Then we test the Reflexes:
  • L4 – The knee reflex.
  • S1 – The ankle reflex.

Reflexes

• Knee (L3-4)

• Ankle (S1-2)

Motor Testing

• Ankle plantar flexion

• Ankle dorsiflexion

• Walking on
  toes SI

• Walking on
  heels L5

Sensory Testing

• Sciatic nerve (L4,5,S1,2)
• Sensory distribution of the sciatic nerve