Back Examination

Question 1

Introduction

Answer 1

Hello I’m An, a 4th year medical student.
Can I confirm your name and DOB
I’ve been asked to perform a back examination, this’ll involve me having a look and feel of your back, and I’ll ask you to perform some movements.

Do you have any questions

Question 2

General inspections
-clinical signs
-objects or equipment

Answer 2

Clinical signs
Body habitus - obesity
Scars - past spinal surgery
Muscle wasting - disuse atrophy from other pathology

Objects, equipment
Walking aids, wheelchairs
Prescriptions - analgesia

Question 3

Close inspection
-anterior
-lateral

Answer 3

Front
-pectus excavatum, carinatum
-level of shoulder and pelvis

Side
-spinal curvature - normal, abnormal lordosis and kyphosis in cervical, thoracic, lumbar regions

Back - skin
-scars
-cafe au lait marks - NF?
-hairy patch - spina bifida

Back - muscle spasm

Back - scoliosis
-palpate down length of spine
If they have scoliosis, ask patient to bend forward
-functional - resolves on back flexion
-structural - more pronounced

Question 4

Gait exam - normal gait cycle

Answer 4

Walk to the end of the examination room, turn and walk back

Normal gait cycle
1. heel strike
2. foot flat
3. mid stance
4. heel off
5. toe off
6. swing

Question 5

Gait exam
-gait abnormalities
-turning abnormalities

Answer 5

Reduced ROM - chronic joint pathology? (OA, RA)

Antalgic - pain or weakness

Trendelenburg - unilateral hip abductor weakness from superior gluteal nerve lesion/L5 radiculopathy

Waddling - bilateral hip abductor weakness from myopathies

Turning - restrictions in joint ROI or instability

Footwear

Question 6

Screening tests for nerve root function
-S1
-L4/L5
-wall test

Answer 6

S1 - plantarflexion
-both feet, tiptoes
-stand on 1 foot, tiptoes, repeat with other

L4/L5 - dorsiflexion
-both feet, on heels
-stand on 1 foot, heels, repeat with other

Wall test
-stand against heels against wall, try to touch head against wall => kyphosis in AS will prevent head from touching wall

Question 7

Palpation

Answer 7

Spinous process - occiput to sacrum
-ask patient to report tenderness
-temp changes

Paravertebral - muscles lateral to spinal column
-muscles lateral to spinal column
-facet joints (2 fingers breadths eaither side of spine, both sides together) - ask patient to report tenderness

Chest expansion
-pump handle
-bucket handle

Question 8

Movement
-active

Answer 8

Cervical
FLEX - chin to chest
EXT - look to ceiling
LAT FLEX - ear to shoulder
ROTATION - turn head left to right

Thoracic
ROTATION - cross arms over chest, twist round to left then right

Thoracic + lumbar
FLEX - bend forward to touch toes
EXT - hands on hips and bend as far back as possible
LAT FLEX - slide hand down side of leg as far as possible with straight legs

Assess for any restriction in ROM, signs of discomfort
-crepitus, RROM, discomfort

Question 9

Special tests
-Schobers test

Answer 9

Identify restricted lumbar flexion

1. Find dimples of Venus
2. Mark skin at midline of DoV and 10cm above (L5)
3. Ask patients to touch toes
4. Measure distance between marks
   -Should increase by 6-7cm

If not => RROM (AS?)

Question 10

Special tests
-SLR

Answer 10

Identify sciatic nerve irritation

1. Supine on couch
2. Hold ankle, raise leg and passively flex hip with knee extended
   -normal ROM - 90deg
3. Once hip flexed, dorsiflex foot
4. Test other side

Positive => pain in posterior thigh, buttock
-sciatic nerve irritation (2ndary to lumbar disc prolapse

Question 11

Special tests
-femoral nerve stretch test

Answer 11

Identify femoral nerve irritation

1. Prone on couch
2. Flex knee to 90deg, extend at hip
3. Plantarflex foot

Positive => pain in thigh, inguinal region

Question 12

Further assessments

Answer 12

NV exam of UL, LL
Examine hip and shoulder
Further imaging - Xray/MRI