What are the components of a normal back exam?

Components of a Normal Back Examination

A comprehensive back examination should include inspection, palpation, range of motion testing, neurological assessment, and special tests to properly evaluate back pain and identify potential causes of morbidity and mortality.

Inspection

• Observe the patient standing from anterior, posterior, and lateral views
• Assess for:
  • Posture and alignment
  • Spinal curvature (lordosis, kyphosis, scoliosis)
  • Symmetry of shoulders, scapulae, and iliac crests
  • Muscle atrophy or hypertrophy
  • Skin changes (scars, rashes, birthmarks)
  • Visible deformities

Palpation

• Palpate the spinous processes from cervical to sacral spine
• Assess paraspinal muscles for tenderness, spasm, or asymmetry
• Palpate sacroiliac joints and greater trochanters
• Note areas of tenderness, masses, or abnormal temperature

Range of Motion Testing

• Assess the following movements:
  • Forward flexion (touch toes)
  • Extension (backward bending)
  • Lateral flexion (side bending to right and left)
  • Rotation (twisting to right and left)
• Note any limitations, pain with movement, or asymmetry

Neurological Examination

• Motor strength assessment of key muscle groups:
  • L4 nerve root: knee extension (quadriceps)
  • L5 nerve root: great toe and foot dorsiflexion
  • S1 nerve root: foot plantarflexion
• Sensory testing in dermatomal distributions
• Deep tendon reflexes:
  • Patellar reflex (L4)
  • Ankle reflex (S1)

Special Tests

• Straight-leg raise test: With patient supine, passively raise the straightened leg between 30-70 degrees. Positive if it reproduces sciatica 1
• Crossed straight-leg raise test: Raising the unaffected leg reproduces pain in the affected leg (more specific but less sensitive) 1
• Femoral nerve stretch test (for upper lumbar radiculopathy)

Red Flag Assessment

Evaluate for concerning features that may indicate serious pathology:

• Severe or progressive neurological deficits
• Bowel or bladder dysfunction (cauda equina syndrome)
• Fever or unexplained weight loss (infection or malignancy)
• History of cancer, trauma, or immunosuppression
• Age >50 years with new onset back pain 1

Common Pitfalls and Caveats

1. Failure to perform adequate inspection occurs in approximately 43% of back examinations 2, yet visual assessment is crucial for identifying structural abnormalities.

2. Reliability of many back examination procedures is variable. According to research, most commonly used procedures demonstrate low reliability 3, making it essential to perform a thorough, standardized examination.

3. Manual fixation techniques during testing require proper training. Tests requiring manual fixation have shown significantly lower reliability when performed by examiners without formal medical education 4.

4. Range of motion measurements are most accurate when:

   • Proper landmarks are identified
   • The measurement device is properly positioned
   • The examiner is adequately trained 5

5. The neurological examination is particularly important as it can identify nerve root compression requiring urgent intervention. Failure to perform this component can miss serious pathology.

By following this structured approach to back examination, clinicians can effectively evaluate patients with back complaints and identify those requiring further investigation or urgent intervention, ultimately improving patient outcomes related to morbidity and mortality.