for the primary care clinician low back pain: focused exam

For the Primary Care clinician

Low Back Pain: Focused Exam

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

• 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

• 7 Cervical vertebrae• 12 Thoracic vertebrae• 5 Lumbar vertebrae• Sacrum (5 fused)• Coccyx (4 fused)

• Focus today on lumbar/sacral spine

Anatomy review

• Vertebra• Intervertebral discs• Facet joints• Spinal nerve• Epidural space

Anatomy review

Pain generators

• 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, GJ et al. Nonorganic physical signs in low back pain. Spine. 5:117-25, 1980.

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.