BACK EXAM UPDATED

Wm. MacMillan Rodney, M.D., FAAFP, FACEP

Original 1977 Updated Mar. 3, 2003

 

 

 

 

I.                   Goals: Develop Skills and Knowledge about Low Back Pain

II.                Objective:

1.                  Provide syllabus

2.                  Publish syllabus on website

3.                  Follow SOAP format.

4.                  Provide Evidence-based Medical Literature.

 

III.             Subjective:

 

A.    Past Medical History (current medications, previous surg., allergies, smoking, alchohol disabilities, Female history)

B.     Analysis of symptom. (PQRST – Rodney’s Dozen)(see website Donna)

 

1.                  Region Where is it?

2.                  Does it radiate? Where?

3.                  When did it start?

4.                  1st Time ever had this kind of pain?  Yes No

5.                  Constant or Intermitent?

6.                  Onset Sudden or Gradual?

7.                  Quality: What’s it like?  Sharp/Dull

8.                  Change in ADL (eat, sleep, work, sex)?

9.                  Quality 1-10 with 10 terrible

10.              Palliated by

11.              Provoked by Anything Else?

12.              What do you think caused it?

 

C.    Present Illness

 

1.                  Mechanics of injury.

2.                  History of previous injury.

3.                  Muscle weakness.

4.                  Paresthesias, tingling

5.                  Bowel, bladder function

6.                  Goals of visit.

7.                  Special issues.

 

                                   

D.    Review of Systems (See handout)

 

1.      Occupation

2.      Secondary gain?

3.      Night Pain?

4.      List Pertinent Positives

5.      List pertinent negatives

6.      Items of uncertain significance.

 

 

IV.              Objectives + Findings:

 

A.    Vital Signs

B.    Inspect

 

1.

a.        Is the patient alert,  cooperative,  and in no acute distress (NAD)?

b.      Affect – Describe the patient’s emotional state.

           

 

2.      Check for Alignment of anatomical landmarks

 

                        a)            Shoulders

                        b)            Scapulae

                        c)            Flank creases

d)                  Gluteal creases

e)                  Popliteal creases

 

 

3.            Observe Spine Curvature

 

                        a)            Scoliosis?

                        b)            Kyphosis?

 

4.            Test for Gait

 

                        a)            Regular

                        b)            Toe – S1 Root/L5-S1 Space

                        c)            Heel – L5 Root/L4-L5 Space

                        d)            Tandem (Also check for Romberg’s sign)

 

4.                  Measure Range of Motion; Observe for pain and/or limited range of motion during these activities.

 

                        a)            touch toes knees straight.

                        b)            walking up legs (sit up while supine)

c)             side bending

 

 

                   Clinical Pearl

 

Spondylolisthesis ?

 

a. Disc-better when sitting versus ruptured disc.

b.       bending increases the pain with disc.

 

B. Palpate (patient still standing)

1.         The bony posterior spines and the intervertebral space..

2.            parapinous muscles

3.            Sacroiliac joints.  If tender confirm this finding with reference, to Gaeuslin Test in book by       Hoppenfeld, p.261

4.         Coccyx pain evaluation should be done with rectal exam

5.         For sciatic notch pain, have patient flex hip (reference Hoppenfeld).

 

Clinical Pearl

Sacroiliac involvement suggests severe disease (e.g., ankylosing spondylitis, check chest expansion)

C. Seated on Table

1.           Inspect patient’s discomfort while getting on and off the table.

2.           Observe – knee extension and measure with goniometer.

 

a)      Reconcile findings with other tests

b)      Litigation Lumbago maneuvers

1.      Rodney’s Rules

2.      Rodney’s Pearls

 

3.            Palpation

 

a)      Circulation – pulses, warmth, symmetry

b)      Neurological exam –

1.      The key tests are touch and a Babinski Reflex.

2.       Other tests such as proprioception, vibratory (extra), touch – sharp-dull, usually don’t add much.

3.      Reflexes- Measure

 

                                    a)             Knee Jerk L3 – L4 (L4 root)

 

                                                b)             Ankle Jerk L5-S1 (S1 root)

 

c)            The Babinski Reflex is a long tract sign.

 

 

 

 

 

 

D. Supine on Table

 

1.         Inspect by measuring

 

a)                  leg length

 

b)                 thigh circumference

 

c)                  calf circumference

 

2.       Range of motion maneuvers to be performed

 

a)      SLR (Straight Leg Raise)

 

b)      SST (Sciatic Stretch  Test)

 

c)      Kernigs, knee extension without dorsiflexion of foot.

 

3.          Patrick-Faberge test for hips

 

a)      The maneuver is external rotation with the hip and knee flexed. Then abduct the externally rotated  femur.

 

b)      Press soles against each other and externally rotate, or rotate outward with the foot resting on the contra lateral patella

 

c)      May stress sacroiliac joint by pressing down knee and contralateral ASIS (Anterior Superior Iliac Spine).

 

4.          Validity Checks

 

a)      Patient “walks up” to sitting position

b)      Rodney’s Secret Rules.

 

5.          Gaenslin Test for SI joint

 

a)      Maneuver – extends hip while standing

 

b)      Can also be done prone

 

 

6.          Mandatory area for examination – abdomen including check for bruits and pulsatile masses.

 

 

 

 

E. Patient rolls to side

 

1.                  Examine prostrate

 

a)      especially coccyc

 

2.                  Twist trunk by hips face to the side while the upper torso becomes supine

 

a)      This stresses L5-S1

 

F. Prone

 

1.                 Validity-----lift trunk and legs simultaneously

 

G. Validity Summary

 

1.                  Facies

 

2.                  SLR confirmed sitting

 

3.                  “walks up” from touching toes from supine

 

4.                  Cannot lift trunk and legs simultaneously

 

5.                  Pain worse when knee flexes

 

 

H. Lab w/u

 

1.                  X-ray lumbar spine if red flags are found in the history and/or high risk and/or no improvement after 4-6 weeks.

a)      AP, lat, obliques of spine

b)     AP and Lateral of hips may be considered

c)      Coccyx coned view (optional)

 

 

2.                  Blood

a)      CBC without diff

b)     ESR or CRP

c)      Uric acid

d)     RF, ANA

e)      Glucose

 

3.                  Neuro

a)      EMG bilat sciatic nerve distribution if consistent physical findings exist (optional)

 

 

I. Management

 

1.                  Bed rest, not bed bound

 

a.       Local moist heat and/or hot soak in a bath tub

b.      May use liniment

c.       If prescribing meds, use schedule time contingent

2.                  ASA

3.                  Motrin 400-800 mg  q6h

4.                  Check stomach irritation at 2d

5.                  Valium (may inhibit activity to desired effect) Consider Ativan (lorazepam)

6.                  Commonly used but not recommended as first line drugs

Robaxin

Flexeril

Oxycontin

Narcotics of any kind.

 

2.                  After 2 days do follow-up visit and recommend Williams exercises instead of physical therapy. Follow up 1 week. Patient does not need referral to receive physical therapy in the early stages.

 

 

 

 

References to Consider

 

1.                  Hoppenfeld Textbook on Examination of the Spine and Extremities

 

2.                  Ferguson. Surgery of Ambulatory Patient

 

3.                  Calliet series

 

List references from the syllabus