What physical examination is appropriate for a patient presenting with spontaneous lower back pain?

Comprehensive Physical Examination for Lower Back Pain

A thorough physical examination for lower back pain should include neurological examination, palpation of spinous processes, assessment of curvature, gait testing, range of motion evaluation, and examination for skin abnormalities to properly categorize the patient and guide treatment decisions. 1

Initial Assessment and Classification

• Conduct a focused history and physical examination to categorize patients into one of three groups: nonspecific low back pain (85% of cases), back pain with radiculopathy or spinal stenosis, or back pain associated with a specific spinal cause 1, 2
• Screen for red flags that may indicate serious underlying conditions requiring prompt evaluation, including history of cancer, unexplained weight loss, failure to improve after 1 month, age older than 50 years, fever, recent infection, significant trauma, or neurologic deficits 1, 2, 3
• Assess for psychosocial factors (yellow flags) that predict risk for chronic disabling back pain, including depression, passive coping strategies, job dissatisfaction, higher disability levels, disputed compensation claims, or somatization 1, 2

Essential Physical Examination Components

Neurological Examination

• Perform a complete neurological assessment including motor strength, sensory testing, deep tendon reflexes, and straight leg raise test for radiculopathy 1, 3
• Assess for rapidly progressive or severe neurologic deficits, including motor deficits at more than one level, fecal incontinence, and bladder dysfunction (cauda equina syndrome) 1, 2

Musculoskeletal Assessment

• Palpate the spinous processes for tenderness, which may indicate vertebral compression fracture or possible vertebral infection if accompanied by fever 1, 3
• Evaluate spinal curvature for abnormalities suggesting scoliosis or kyphosis 1, 2
• Assess gait pattern for abnormalities that may indicate neurological involvement or mechanical issues 1, 3
• Test range of motion in all planes (flexion, extension, lateral bending, rotation) and note any limitations or pain provocation 1, 2

Skin and Soft Tissue Examination

• Examine the skin over the spine for abnormalities such as dimpling, hairy patches, or discoloration that might suggest underlying congenital abnormalities 1, 2
• Assess for muscle spasm, asymmetry, or atrophy 2, 3

Special Tests and Considerations

• Perform straight leg raise test to evaluate for lumbar radiculopathy (sciatica) 1, 3
• Consider femoral nerve stretch test for upper lumbar radiculopathy 3, 4
• Evaluate for signs of spinal stenosis, including pseudoclaudication (leg pain with walking that improves with sitting) 1, 2
• Assess for non-spinal causes of back pain, such as hip pathology, sacroiliac joint dysfunction, or referred pain from visceral organs 2, 4

Common Pitfalls to Avoid

• Failing to recognize red flags that may indicate serious underlying conditions requiring urgent attention 2, 3
• Overreliance on imaging without appropriate physical examination 1, 3
• Not assessing psychosocial factors that may contribute to pain perception and chronicity 1, 2
• Inadequate neurological examination, particularly when assessing for cauda equina syndrome 1, 3

Follow-up Recommendations

• Reevaluate patients with persistent, unimproved symptoms after 1 month 1, 3
• Consider earlier reassessment for patients with severe pain or functional deficits, older patients, or patients with signs of radiculopathy or spinal stenosis 1, 3
• If symptoms persist beyond 4-6 weeks despite conservative management, consider appropriate imaging and specialist referral 3, 5

The physical examination findings, combined with a thorough history, will help guide appropriate management decisions and identify patients who require immediate intervention or further diagnostic evaluation 1, 2.