What characterizes a normal back exam?

Normal Back Examination

A normal back examination reveals no pain, tenderness, deformity, or neurological deficits, with full range of motion and no red flags suggesting serious underlying pathology. 1

Key Components of a Normal Back Examination

Inspection

• Normal spinal alignment without visible deformity
• Symmetrical paraspinal muscles without atrophy
• No skin changes (rashes, scars, or discoloration)
• No visible swelling or masses

Palpation

• No tenderness over spinous processes, facet joints, or paraspinal muscles
• No paraspinal muscle spasm
• No step-offs or gaps between vertebrae
• No sacroiliac joint tenderness

Range of Motion

• Full flexion, extension, lateral bending, and rotation without pain
• Smooth, coordinated movement patterns
• No pain at end ranges of motion

Neurological Examination

• Normal strength (5/5) in all major muscle groups of lower extremities
• Normal and symmetrical deep tendon reflexes
• Normal sensation to light touch and pinprick in all dermatomes
• Negative straight leg raise test (no radicular pain with leg elevation)
• Normal gait pattern

Special Tests

• Negative Spurling's test (no radicular symptoms with cervical compression)
• Negative FABER test (Flexion, ABduction, External Rotation)
• Negative Slump test (no reproduction of symptoms with seated neural tension testing)

Red Flags to Document as Absent in a Normal Examination

A thorough back examination should document the absence of these red flags:

• No history of significant trauma 1, 2
• No constant or night pain 1
• No radicular symptoms 1
• No abnormal neurological findings 1
• No bowel or bladder dysfunction 1, 3
• No saddle anesthesia 3, 4
• No fever, chills, or recent infection 1, 4
• No history of cancer or unexplained weight loss 5, 4
• No immunosuppression 4

Documentation Approach

When documenting a normal back examination, it's important to:

1. Systematically address all components of the examination
2. Explicitly note the absence of red flags
3. Document normal findings in specific terms rather than general statements

Sample Documentation Format

BACK EXAMINATION:
Inspection: Normal spinal alignment, no visible deformity or asymmetry
Palpation: No tenderness over spinous processes, facet joints, or paraspinal muscles
Range of Motion: Full and painless flexion, extension, lateral bending, and rotation
Neurological: 5/5 strength throughout, symmetric reflexes, intact sensation in all dermatomes
Special Tests: Negative straight leg raise, negative FABER test
Red Flags: No constant/night pain, no radicular symptoms, no bowel/bladder dysfunction, no saddle anesthesia

Common Pitfalls to Avoid

1. Failing to document the absence of specific red flags 4
2. Using vague terminology like "normal exam" without specific details
3. Overlooking documentation of bowel/bladder function and saddle anesthesia, which are critical for ruling out cauda equina syndrome 3
4. Neglecting to document negative findings for weight loss, recent infection, and fever/chills (commonly missed red flags) 4
5. Assuming that the absence of one or two red flags rules out serious pathology (multiple red flags together provide better specificity) 5, 3

Remember that a truly normal back examination should include comprehensive documentation of all key components and explicitly note the absence of red flags to establish baseline findings for future comparison.