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

Lumbar Spine Physical Exam Template for Chronic Back Pain

For a patient with chronic back pain, the physical examination should include a focused neurologic and musculoskeletal evaluation with specific attention to identifying red flags, radiculopathy, spinal stenosis, and psychosocial risk factors. 1

General Inspection and Posture

• Gait assessment: Observe for antalgic gait, Trendelenburg sign, or abnormal movement patterns 1
• Spinal alignment: Note any scoliosis, kyphosis, or lordosis 1
• Skin examination: Inspect for café-au-lait spots, hairy patches, or dimpling suggesting underlying spinal pathology 1

Range of Motion

• Lumbar flexion: Forward bending, measure fingertip-to-floor distance 1
• Extension: Backward bending 1
• Lateral flexion: Side bending bilaterally 1
• Rotation: Twisting motion to both sides 1
• Note: Document any pain reproduction with specific movements and whether pain improves or worsens with activity versus rest 1

Palpation

• Spinous processes: Palpate L1-S1 for tenderness or step-offs 1
• Paraspinal muscles: Assess for spasm, tenderness, or asymmetry 1
• Sacroiliac joints: Palpate bilaterally for tenderness 1
• Sciatic notch: Assess for tenderness suggesting piriformis involvement 1

Neurologic Examination

• Motor strength testing (graded 0-5/5): 1

  • L2-L3: Hip flexion (iliopsoas)
  • L3-L4: Knee extension (quadriceps)
  • L4-L5: Ankle dorsiflexion (tibialis anterior)
  • L5-S1: Great toe extension (extensor hallucis longus)
  • S1: Ankle plantarflexion (gastrocnemius/soleus), have patient walk on toes

• Sensory examination: 1

  • L2-L3: Anterior thigh
  • L4: Medial leg and foot
  • L5: Lateral leg and dorsum of foot
  • S1: Lateral foot and sole

• Deep tendon reflexes: 1

  • Patellar (L4)
  • Achilles (S1)
  • Document as normal, diminished, or absent

Special Tests for Radiculopathy

• Straight leg raise (SLR): Positive if radicular pain reproduced between 30-70 degrees of hip flexion with knee extended 1
• Crossed straight leg raise: Contralateral leg raising reproduces symptoms in affected leg (highly specific for disc herniation) 1
• Slump test: Seated patient flexes spine, extends knee; positive if reproduces radicular symptoms 1
• Femoral nerve stretch test: Patient prone, knee flexed, hip extended; positive if reproduces anterior thigh pain (L2-L4 radiculopathy) 1

Tests for Spinal Stenosis

• Two-stage treadmill test: Symptoms worsen with walking and improve with sitting or forward flexion 1
• Bicycle test: Symptoms improve with forward-leaning position versus upright walking 1

Red Flag Assessment

Document presence or absence of: 1, 2

• Constitutional symptoms: Fever, unexplained weight loss, night sweats
• Bowel/bladder dysfunction: Urinary retention, incontinence, saddle anesthesia (cauda equina syndrome)
• Progressive neurologic deficit: Worsening weakness or sensory loss
• History of cancer: Especially with new onset back pain
• Recent infection or immunosuppression: Risk for spinal infection
• Trauma history: Relative to patient's age and bone density
• Age >50 or <20 years: Higher risk for serious pathology
• Chronic steroid use: Risk for compression fracture

Psychosocial Evaluation (Yellow Flags)

Document: 1, 2

• Pain characteristics: Onset, quality, intensity (0-10 scale), distribution, duration, course 1
• Functional impact: Ability to work, perform activities of daily living, sleep disturbance 1
• Psychological symptoms: Depression, anxiety, anger, catastrophizing 1
• Coping mechanisms: Active versus passive strategies 2
• Occupational factors: Job satisfaction, disputed compensation claims 2
• Social history: Substance use or misuse 1

Additional Musculoskeletal Assessment

• Hip examination: Range of motion and FABER test to rule out referred pain from hip pathology 2
• Sacroiliac joint provocation tests: FABER, Gaenslen's, thigh thrust, compression, and distraction tests 1
• Abdominal examination: Palpate for masses or pulsatile abdominal aorta if vascular etiology suspected 1

Documentation of Mechanical Stress Factors

Note: 1

• Occupational demands: Type of work, lifting requirements
• Physical activities: Sports participation (soccer, riding, long-distance running)
• Body habitus: Obesity
• For women: Pregnancy history (number of children, date of most recent delivery)

Common Pitfall: Many imaging abnormalities such as disc bulges are common in asymptomatic individuals and may not correlate with symptoms, so clinical correlation is essential. 2 The physical examination findings should guide management decisions rather than imaging findings alone. 1, 2