Examination of the Back

“More mistakes are made from want of proper examination than for any other reason.”

—Russell Howard

“The examining physician often hesitates to make the necessary examination because it involves soiling the finger.”

—William Mayo

The purpose of this chapter is to give a general outline of a routine clinical examination of a patient suffering from significant back pain. Specific findings are alluded to again when the examination and treatment of common clinical syndromes are discussed in later chapters. It is important to emphasize that accurate records of the history and examination should be made. These must include exact measurements and not vague terms such as “good,” “poor,” “limited,” and so on. Good records are necessary for case analysis and comparison, and, on case reviews, for assistance to a consulting physician, and, at times, for legal purposes.

The examination of the back should be conducted in an orderly, predetermined manner. Examination of the patient should not be directed solely at eliciting signs of a specific disease suggested by the history, nor should individual systems be examined serially: neurologic examination, abdominal examination, vascular examination, and so on. The examination must be conducted in an orderly manner so that all possible physical findings may be evaluated. When you finish examining each patient, you must know as much about his or her physical state as the last patient and every patient you have seen or will see.

The first prerequisite is that the patient must be undressed. To some practitioners, this is an absurd statement, because patient undressing is a routine; to clinicians who see a lot of patients in a short amount of time, patient undressing is an inconvenience. A cursory examination is worse than no examination at all, because it may give the false hope that the lesion is minor.

Step 1 Gait

Watch the patient walk. Is there an antalgic gait that suggests hip or knee disease? Is there a shuffling gait that suggests a neurologic disorder of rigidity or spasticity? Does the patient walk slightly flexed, which suggests a spinal canal stenosis? Gait observation reveals a lot of secrets. Not infrequently, it is difficult to decide if a patient’s back and hip pain is due to pathology in the back or in the hip. More often than not, watching the patient walk the length of the hall will make the diagnosis, especially if the patient has the spastic gait of myelopathy or the antalgic limp of hip disease.

Step 2 Spine Contours

By looking at the patient from the side and behind, gross postural changes will be evident. It is best to think of these postural changes as being in the sagittal plane (Fig. 9-1) or the coronal or frontal plane (Fig. 9-2).

FIGURE 9-1 Sagittal plane malalignment: kyphosis.

FIGURE 9-2 Coronal plane malalignment: scoliosis.

Frontal Plane Asymmetry

There are three basic causes of frontal plane asymmetry as shown in Figure 9-2. To separate a structural scoliosis (e.g., idiopathic) from a sciatic scoliosis, make the following observations:

STRUCTURAL SCOLIOSIS

The curve is fixed and does not change on forward flexion.
The common right thoracic idiopathic curve has a rib hump that becomes more obvious on flexion.
The curve does not reduce on recumbency.

SCIATIC (REACTIVE) SCOLIOSIS

Sciatic scoliosis is a more diffuse curve that does not have a rib hump.
On forward flexion, the curve changes, usually becoming worse, but it may even reverse its direction.
Forward flexion in sciatic scoliosis is much more limited than that in structural scoliosis.
Sciatic scoliosis usually disappears on recumbency.

Other observations to be made when examining the patient from behind are as follows:

Look for skin crease changes in the lumbosacral regions that might indicate a step-off of a lytic or degenerative spondylolisthesis [see Chapter 6, “Steps” of spondylolisthesis (Fig. 9-3)].
Skin markings: look for café-au-lait spots, a hallmark of neurofibromatosis. Other masses such as fatty tumors or hairy patches in the lumbosacral region may indicate deeper skeletal lesions such as spina bifida with or without associated tumors of or in neurogenic tissues.

FIGURE 9-3 The “steps” in spondylolisthesis. A: In a lytic spondylolisthesis (most common at L5-S1), the spinous process of L5 is left behind, that is, the step is palpable between the L4 spinous process that has moved forward and the L5 spinous process. B: In a degenerative spondylolisthesis, a similar situation exists, except the slip vertebrae is one level higher, and the L5 spinous process is also left behind.

Step 3 Range of Motion/Rhythm

The range and rhythm of spinal movement are tested next. The range of forward flexion is recorded by noting how far the hands come toward the floor. The rhythm of forward flexion is observed by placing the fingertips on the spinous process and noting how far they separate on flexion of the spine (Fig. 9-4).

FIGURE 9-4 When the patient is asked to bend forward, not only should the range of movement be noted, but the ability of the spinous processes to separate should also be recorded. This is best done by placing the fingertips over the spinous processes in the lumbar spine.

Extension is recorded by noting how far the patient can lean backward before the pelvis tilts. Lateral flexion is measured by noting how far the patient can slide the hand down the thigh toward the knee (Fig. 9-5). Rotation can be tested by getting the patient to stand with his or her feet wide apart and rotate with hands on hips (Fig. 9-6). Also, do the simulated rotation test demonstrated in Chapter 16.

FIGURE 9-5 Lateral flexion is recorded by noting how far the patient can slide his or her hand down the thigh toward the knee.

FIGURE 9-6 Rotation is recorded by asking the patient to place his or her hands on the hips. The elbows then act as the arms of a goniometer and the degree of rotation permitted can be measured.

During the examination, observe any specific abnormalities; for example, look for marked limitation of the range of forward flexion without lumbar movement, as occurs in root irritation due to disc herniation. These patients frequently show deviation to the painful side on forward flexion. The rigidity of the whole spine in the later stages of ankylosing spondylitis is characteristic. Reversal of normal spinal rhythm on attempting to regain the erect posture after forward flexion is characteristic of disc degeneration associated with a posterior joint lesion. To avoid putting an extension strain on the posterior joint, the patient tucks the pelvis under the spine to regain the erect position. When getting up from forward flexion, he or she will start to extend the spine, but this
movement is uncomfortable. To avoid this, he or she will slightly flex the hips and knees to tuck the pelvis under the spine and then regain the erect position by straightening the legs (Fig. 9-7).

FIGURE 9-7 Reversal of spinal rhythm. On attempting to regain the erect position from forward flexion, the patient will bend the knees and tuck the pelvis underneath the spine to stand erect. This type of movement is very characteristic of segmental instability.

With the patient still standing, the strength of the gastrocnemius is determined by testing the ability to stand on tiptoe (Fig. 9-8). Repetitive toe raising (fatigue testing) may bring out early changes. Lesions involving the first sacral root such as lumbosacral disc herniation may produce weakness of tiptoe raising and diminution of the ankle jerk, which can be tested with the patient kneeling on a chair. The examiner must remember that if a patient has a weak quadriceps, his or her leg will tend to buckle on attempting to rise on tiptoe. This is a diagnostic trap for the unwary.

FIGURE 9-8 The strength of the gastrocnemius is best tested by asking the patient to rise on tiptoe repetitively and rapidly. You are looking for fatigability, and therefore the patient must be asked to rise on tiptoe a minimum of 10 times.

Step 4

Two examinations are conducted with the patient sitting on the edge of the examining table. First, examine the knee and ankle reflexes. This is usually the most comfortable position for a back pain patient and allows for reflex examination without painful posturing, something that will distort the reflex examination. Every now and then, a patient will have such a great degree of sciatica that he or she cannot sit without lifting the buttock (and thus the painful sciatic nerve) off the bed, which may falsely suppress the knee reflex. Reflexes can also be altered by a patient visually watching the reflex examination. This can be negated by reinforcement (Fig. 9-9).

FIGURE 9-9 A: Asking the patient to grasp and pull on the hands serves as reinforcement of reflexes. B: Sitting Babinski’s test: the straight leg raising (SLR) test can be done in the sitting position while doing other tests, such as that to test Babinski’s reflexes.

The next reflex to be tested is the superficial plantar-flexor response (see Fig. 9-9). One feature of the plantar response is a reflex contraction of the tensor fascia femoris. This portion of the withdrawal response is lost with lesions involving S1.

Oh, by the way! Go back to Figure 9-9

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