What are the key components of a normal lumbar exam in an adult patient with no significant past medical history?

Normal Lumbar Spine Examination Documentation

A normal lumbar examination in an adult should document inspection findings (no visible deformity, normal posture, symmetric paraspinal musculature), full pain-free range of motion in all planes, negative straight leg raise bilaterally, intact motor strength (5/5) in L4-S1 distributions, symmetric reflexes, and normal sensation in lower extremity dermatomes. 1, 2

Inspection Components

• Posture and alignment: Document absence of scoliosis, kyphosis, or lordotic abnormalities, though postural analysis has shown poor agreement even in validated assessment protocols 3
• Skin examination: Note absence of skin abnormalities, lesions, or signs suggesting underlying pathology 4
• Paraspinal musculature: Observe for symmetry and absence of visible spasm or atrophy 5
• Gait assessment: Document normal gait pattern without antalgic features 4

Clinical caveat: Studies show inspection is performed in only 57% of low back pain encounters, representing a significant gap in standard practice 6

Palpation Findings

• Spinous processes: Document absence of tenderness along L1-L5 and sacrum 4
• Paraspinal muscles: Note absence of spasm, trigger points, or focal tenderness 5
• Sacroiliac joints: Palpate bilaterally without eliciting pain 5

Important note: Palpation is omitted in approximately 20% of provider encounters for low back pain, despite being a fundamental examination component 6

Range of Motion Assessment

Document the following movements as full and pain-free:

• Flexion: Normal forward bending with fingertips reaching toward toes 7, 8
• Extension: Backward bending without pain or limitation 7, 8
• Lateral flexion: Side bending right and left, symmetric bilaterally 7, 8
• Rotation: Twisting motion right and left, symmetric 7, 8

Age consideration: Expect physiologically decreased range of motion with increasing age; normal values vary significantly across age groups, with substantial decreases expected in older patients 7

The interobserver reliability for lumbar ROM measurements is excellent (ICC 0.91-0.98) when using standardized techniques 8

Neurological Examination

Motor Testing (Document as 5/5 bilaterally)

• L4 nerve root: Knee extension strength and quadriceps function 1, 2
• L5 nerve root: Great toe dorsiflexion and foot dorsiflexion strength 1, 2
• S1 nerve root: Foot plantarflexion and ankle strength 1, 2

Reflex Testing (Document as 2+ and symmetric)

• Patellar reflex: Tests L4 nerve root 1
• Ankle reflex: Tests S1 nerve root 1, 2

Sensory Examination

• L4 dermatome: Medial leg and foot 1
• L5 dermatome: Lateral leg and dorsal foot 1
• S1 dermatome: Lateral foot and sole 1

Document as intact to light touch bilaterally without dermatomal deficits 1, 2

Special Tests

Straight Leg Raise (SLR)

• Technique: Passively raise extended leg while patient supine 1, 3
• Normal finding: Negative bilaterally (no radicular pain below the knee) 1, 2
• Documentation: "SLR negative bilaterally to 70-80 degrees without reproduction of radicular symptoms" 3

Critical interpretation: The SLR has 91% sensitivity but only 26% specificity for disc herniation, meaning a negative test is reassuring but a positive test requires clinical correlation 1, 2

Crossed Straight Leg Raise

• Normal finding: No contralateral leg pain when raising the unaffected leg 1
• This test has higher specificity (88%) but lower sensitivity (29%) for disc herniation 1

Functional Assessment

• Heel walking: Tests L5 function (foot dorsiflexion) 5
• Toe walking: Tests S1 function (plantarflexion) 5
• Squat and rise: Assesses overall lower extremity strength and lumbar stability 5

Document as performed without difficulty or pain 5

Documentation Template Summary

A complete normal examination should state:

"Inspection: Normal lumbar lordosis, no visible deformity, symmetric paraspinal musculature, normal gait. Palpation: No spinous process or paraspinal tenderness. ROM: Full and pain-free flexion, extension, lateral flexion bilaterally, and rotation bilaterally. Motor: 5/5 strength in knee extension (L4), great toe/foot dorsiflexion (L5), and foot plantarflexion (S1) bilaterally. Reflexes: 2+ and symmetric patellar and ankle reflexes. Sensory: Intact to light touch in L4, L5, and S1 dermatomes bilaterally. SLR: Negative bilaterally. Functional: Heel and toe walking without difficulty." 1, 2, 5

Practice pitfall: Telehealth examinations show high agreement for detecting pain with movements and SLR testing, but poor agreement for postural analysis, so in-person examination remains superior when feasible 3