What should be included in an auto-text template for dictating a lumbar spine physical exam for a patient with a history of chronic back pain?

Lumbar Spine Physical Exam Auto-Text Template

For a patient with chronic back pain, your lumbar spine physical exam dictation should systematically document inspection, palpation, range of motion, neurological assessment, and provocative maneuvers to identify both mechanical pathology and red flag conditions that would alter management.

Essential Components to Include

Patient Demographics & Context

• Age and sex - Critical for interpreting degenerative findings and differential diagnoses 1
• Duration of back pain (acute <4 weeks, subacute 4-12 weeks, chronic >12 weeks) 2
• Pain characteristics: location (lumbar vs sacroiliac), radiation pattern, inflammatory features (worse with rest, night pain, morning stiffness, improvement with exercise) 1
• Occupational/activity history: physically demanding work, repetitive activities, sports participation 1
• For women: pregnancy history (number of children, date of most recent delivery) as this affects sacroiliac joint interpretation 1

Inspection

• Posture and alignment: lordosis, scoliosis, pelvic tilt 3
• Gait pattern: antalgic gait, Trendelenburg sign, foot drop 2
• Skin changes: surgical scars, café-au-lait spots, hairy patches suggesting spinal dysraphism 4
• Muscle atrophy: asymmetry in paraspinal or lower extremity muscles 3

Palpation

• Spinous processes: tenderness, step-offs suggesting spondylolisthesis 3
• Paraspinal muscles: spasm, trigger points, asymmetric tension 3
• Sacroiliac joints: tenderness over posterior superior iliac spines 1
• Sciatic notch: tenderness suggesting piriformis syndrome 4

Range of Motion

• Flexion: fingertips-to-floor distance or Schober test (mark 10cm above and 5cm below L5, should increase to >15cm with flexion) 3
• Extension: degrees from neutral, reproduction of pain 3
• Lateral bending: left and right, symmetry 3
• Rotation: left and right while seated to isolate lumbar spine 3
• Document pain reproduction with specific movements and whether pain is axial or radicular 2

Neurological Examination (Critical for Radiculopathy Assessment)

Motor Testing 2, 3:

• L2-L3 (hip flexion): iliopsoas strength
• L3-L4 (knee extension): quadriceps strength
• L4 (ankle dorsiflexion): tibialis anterior strength
• L5 (great toe extension): extensor hallucis longus strength
• S1 (ankle plantarflexion): gastrocnemius/soleus strength

Sensory Testing 2, 3:

• L4: medial leg and foot
• L5: lateral leg and dorsal foot
• S1: lateral foot and sole

Reflexes 2, 3:

• Patellar (L4): graded 0-4+
• Achilles (S1): graded 0-4+
• Plantar response: Babinski sign (upgoing toe suggests upper motor neuron pathology)

Provocative Maneuvers

For Radiculopathy 2, 3:

• Straight leg raise (SLR): positive if radicular pain reproduced between 30-70 degrees (L5-S1 sensitivity)
• Crossed SLR: contralateral leg raise reproducing ipsilateral symptoms (highly specific for disc herniation)
• Femoral stretch test: prone patient with knee flexed, hip extended (L2-L4 radiculopathy)
• Slump test: seated patient with neck flexion, knee extension reproducing radicular symptoms

For Sacroiliac Joint 1:

• FABER test (Flexion, ABduction, External Rotation): reproduces SI joint or hip pain
• Gaenslen's test: hyperextension of hip with contralateral hip flexed
• Sacral thrust: posterior-to-anterior pressure over sacrum
• Note: No single physical exam maneuver reliably diagnoses SI joint pain; multiple positive tests increase specificity 5

For Spinal Stenosis 3, 4:

• Two-stage treadmill test: symptoms worsen with walking, improve with sitting/flexion
• Bicycle test: symptoms better with cycling (flexed position) than walking

Red Flags to Document (If Present)

These findings mandate immediate imaging and altered management 2, 3:

• Cauda equina symptoms: saddle anesthesia, bowel/bladder dysfunction, bilateral leg weakness
• Progressive neurological deficit: worsening motor weakness, sensory loss
• Constitutional symptoms: fever, unexplained weight loss, night sweats
• History of malignancy: especially breast, lung, prostate, kidney, thyroid
• Recent significant trauma: relative to age (minor trauma in elderly with osteoporosis)
• Age >50 with new onset pain or age <20 with persistent pain
• Intravenous drug use or immunosuppression: infection risk
• Prolonged corticosteroid use: fracture risk
• Severe, unrelenting pain: especially at rest or night, unresponsive to position changes

Yellow Flags to Note

Psychosocial factors predicting chronicity and disability 2:

• Belief that pain indicates serious harm: catastrophizing
• Fear-avoidance behaviors: activity restriction beyond medical necessity
• Passive coping strategies: reliance on passive treatments
• Work dissatisfaction or compensation issues
• Depression or anxiety symptoms

Sample Auto-Text Structure

LUMBAR SPINE EXAMINATION:
Inspection: Posture [normal/abnormal], alignment [normal lordosis/kyphosis/scoliosis], gait [normal/antalgic/other], no/yes skin changes, no/yes muscle atrophy [location if present]

Palpation: Spinous processes [nontender/tender at ___], paraspinal muscles [no spasm/spasm present], SI joints [nontender/tender], no/yes step-off deformity

Range of Motion: Flexion [fingertips-to-floor ___ cm / Schober ___ cm], extension [___°], lateral bending [symmetric/asymmetric], rotation [symmetric/asymmetric]. Pain [not reproduced/reproduced with ___ movement, axial/radicular pattern]

Motor: Hip flexion 5/5, knee extension 5/5, ankle dorsiflexion 5/5, great toe extension 5/5, ankle plantarflexion 5/5 bilaterally [or specify deficits]

Sensory: Intact to light touch in L4, L5, S1 distributions bilaterally [or specify deficits]

Reflexes: Patellar 2+ bilaterally, Achilles 2+ bilaterally, plantar responses downgoing [or specify abnormalities]

Special Tests: SLR negative/positive at ___° [left/right/bilateral], crossed SLR negative/positive, femoral stretch negative/positive, FABER negative/positive, [other tests as indicated]

Red Flags: None present / [specify if present: cauda equina symptoms, progressive deficit, constitutional symptoms, etc.]

Common Pitfalls to Avoid

• Failing to document pain duration and characteristics limits ability to determine if imaging is indicated, as routine imaging provides no benefit for uncomplicated acute or chronic low back pain without red flags 1
• Omitting detailed neurological exam when radicular symptoms are present prevents accurate localization and surgical planning if needed 2, 3
• Not assessing for red flags systematically can miss serious pathology requiring immediate intervention 2, 3
• Ignoring psychosocial yellow flags misses opportunity for early intervention to prevent progression to chronic disability 2
• Performing only supine examination without functional assessment (gait, standing posture, provocative maneuvers) provides incomplete clinical picture 3