Getting a good back history and correctly performing a back exam
February 21, 2019
Getting a good history is important. Generally a patient will tell the story of what is wrong.
I usually ask, when did your back pain start?
I ask, was there a provocation of precipitating incident?
I ask, was there a fall or a twist or landing on the buttocks or nothing? Sometimes people lift their grandchildren or a dog and they do not realize what they have done.
I ask them to tell me exactly where the pain is. Is it in the back or is it in the leg? And I ask them to be specific. Now I try to get the patient to give me a percentage. Is it 90% back pain or 90% leg pain, and that usually helps specificity. If it is 50/50, which is possible, then it needs to be further examined. If the pain is in the lower back (which it usually is), is it on the left side or the right side, or is it midline? One must differentiate between the back pain and gluteal pain as I will go into later. If it is leg pain, then I ask which leg. Exactly how does the pain travel down to the leg from the back? If it comes from the buttock muscles, which is not part of the back, then it is really not listed as leg pain.
I ask if the pain goes down the back of the thigh, the side of the thigh or the front of the thigh. If it is primary leg pain, is it worse when sitting or with standing. Does the pain go below the knee or does it stay above? If the pain goes down the front of the thigh, the side of the thigh or the back of the thigh, it has a great deal to do with which nerve is affected. If it goes down the back of the thigh, it can be tight hamstrings causing pain if it does not go below the knee. As I said, this has a great deal to do whether it is a neurological problem or a muscle problem. If the pain goes below the knee pretibial or lateral or posterior calf area, that usually tells me something where that neurological origin is in the spine, an L5 root possibly, L4 and definitely an S1 root. Does the pain continue to the side, top or bottom of the foot?
If the pain goes to the backside of the thigh only above the knee, many times the pain is from spasms and ischemia and tight hamstrings which can bother people when they are sitting in a car driving and only relieved with activity which stimulates blood supply.
This supports the fact that it is extreme muscle tightness. If it goes to the bottom of the foot, it fits in with the L5 and S1 nerve root.
BACK PAIN
If you have back pain when you are sitting, I first ask, how long can you sit before you absolutely must change position. Is it 5 or 10 minutes or more? If you can sit greater than one hour, that is usually fine. The next question is, how long can you stand, 5 or 10 minutes or greater than one hour before you cannot stand anymore, and the pain must be severe enough to change position? Standing pain is a heads up for spinal stenosis and facet problems if it is acute and very limiting.
Sitting pain can potentially identify a herniated disc if it primarily worsens a leg problem. It can also signify a degenerative disc with increasing back pain. A degenerative disc at L4-L5 can cause radiating pain to the sacroiliac joint, and a degenerative disc at L5-S1 that is really hot can cause radiating pain perceived to the coccyx. Remember with sitting the disc has 2 to 3 times body pressure on it, causing pain in the disc.
The supine position, when you have the patient lying on their back and sleeping, the question is, does pain awaken you? Sometimes some people sleep in the fetal position on the side which is quite comfortable, and I ask, does the pain awaken you when you are rolling over? This creates a rotation component to a painful degenerative disc which can pinpoint the problem. How many times a night or during the week do you wake up when this pain awakens you? This is a good part of the history.
Again, do you have pain going from sitting to standing? Do you get pain relief with walking? Do you have pain with coughing or sneezing, or do you have any bowel or bladder problems? This can denote some spinal stenosis or partial loss of neurological function. Does walking activity improve or worsen the pain? If walking activity improves the pain, then it can be a muscle problem. If walking activity worsens the pain, then it can be a structural problem, as I mentioned, as a facet or degenerative disc or spinal stenosis. Do you have pain twisting getting in and out of the car? Rotation can cause degenerative disc or facet problems. The simple question of bowel or bladder loss of control would suggest severe neurological compromise from spinal stenosis. I really see this rarely, but I always include it in the history. Any pain with coughing or sneezing or Valsalva with a bowel movement causing leg pain is indicative of a possible disc pressing on a nerve root.
This basically is a summary of getting a physical history of a patient with appropriate answers. Now we will go on to doing an examination of the patient.
BACK EXAMINATION
I usually have the patient disrobe with the underclothes on, standing facing away from me with an open gown. I observe and have the patient point to where the pain is with one finger. I gently press on that area and palpate the paraspinous muscles starting around T5-T6 all the way down to the buttock. I do the left side and the right side. Is it tender? Are the muscles tight? Is it asymmetrical? Are there secondary muscle spasms on one side or the other? Are there signs of scoliosis and a rotational component? Observe with discrimination!
It is symmetrical and a spasm is there that can indicate a degenerative disc at the level of the spasm, a level or two above and below the disc. I palpate for a step-off of the spine. Is there a deformity in the spinous process all the way down to the sacrum? I gently tap on the spine to see if pain increases. This can be a suggestion of an acute compression deformity at that level which can be documented with either a bone scan or an MRI with STIR images. When I place people prone on the exam table, I put direct pressure on the posterior spinous process and I can elicit pain from a painful degenerative disc, but do this gently.
If the patient is standing facing away from me, I have them bend laterally to the left and right (usually about 20 degrees is acceptable depending on age), note where the pain is. This depends on which opposite side the muscle spasm resides.
A disc or nerve compression on side bending can aggravate on the side one bends to for the same leg. I have them twist to the left and twist to the right actively only, no manipulation, and generally they are somewhat limited, especially if they are an older patient. One must assess the spine only. Many people rotate the pelvis and the hip, and this is deceptive. Rotation of the spine is only 5 or 10 degrees, one has to carefully look at that and watch the iliac crest and the spine to assure that only 5 or 10 degrees of left and right rotation occurs.
When one has pain from a degenerative disc or facet, it can be aggravated with the rotation. You must notate that when the patient is standing, the iliac crest is level to rule out a leg length discrepancy. Doing a Trendelenburg of lifting one leg and the other will help determine whether one has a painful degenerative hip. One needs to palpate the gluteus medius at its origin of the sacroiliac joint to the greater trochanter. Is it sensitive or sore? Is it duplicating pain? One can usually palpate a band-like muscle which is really tight, causing the same pain. When the gluteal muscles become spinal extensors, their excursion is stretching is very limited unless professional help is obtained. They can be a significant source of buttock pain and will require focused therapy to stretch these out.
One must palpate the trochanteric bursa over the greater trochanter. Exquisite soreness denotes acute sensitivity. The tightness of this muscle causes an inflammation of this bursa and just injecting it or oral medication, anti-inflammatories, is not going to resolve the problem as it needs to be stretched from its origin at the iliac crest anteriorly to its insertion just below the knee on the lateral aspect of the tibia. Once stretched over several weeks, pressure diminishes reducing a reoccurrence.
Another examination again is extension when the patient has extended or ends up bending backwards 5 degrees, increasing pain comes from facet degeneration. Compression of these facets can cause a problem if they are a source of pain. In a rare instance, pushing on a nerve root can cause perceived leg pain associated with bending backwards with facet subsidence into the foramen.
FLEXION
The next topic is flexion. With the knees straight, standing facing away, I have them bend forward on their own, I warn them not to hurt themselves. I note the flexibility of the lumbar spine. Many lumbar spines are very straight in older people, and they do not bend. All the flexion then occurs through the hip. Overusing the gluteal muscles as spinal extensors with severe spasm and tightening causes pain.
Generally speaking, if the lumbar spine flexes easily, one can note a spasm or a mild rotatory scoliosis deformity. If the flexion is limited in the spine, the hamstring can limit flexibility and this can be a cause of leg pain in the thigh. I then have them walk on their heels and toes with weight-bearing to determine strength and neurological function. When I put the patient on the exam table sitting after this is done, I check the knee reflexes tapping on the patella and the Achilles tendon. If I check the extensor hallucis longus at the same time for normal strength I also check the peroneals, the eversion of the ankle.
Once they are sitting on the exam table and their reflexes are checked, I rotate the hip on the left and right side while they are sitting. If it is a degenerative hip, they will wince or complain. I straighten their leg out to make sure their hamstrings are not tight while they are sitting, but this is a Waddell sign for any disc pain and not substituted for a straight leg raise. A straight leg raise when they are supine on the table can be positive at 30 degrees for a neurological origin by a windlass effect stretching the nerve over a bulging disc duplicating a neurological component. If it is more than 50, 60, 70 or 80 degrees, then it becomes a myofascial component as the hamstrings will tilt the pelvis irritating the lower back, aggravating facets degenerative disc and tight muscles.
I have also had patients (after the straight leg raise is assessed) hold their leg up and check their hip flexors and their quads by pushing down on their leg and trying to bend their knee when they are holding it out straight. Generally if this is weak, that points to a neurological problem related to muscle weakness which should be the L3, L4 and L5 nerve roots. If one is unable to break the quads or hip flexors, then it is normal.
Lastly, I would have them bend their knees, bring their heels to their buttocks in the supine position and have them try to do a sit-up, only if there is no leg pain, I will assist them if needed to see if they can mechanically do a sit-up. If there is weakness, the assistance is needed. This can prove a mechanical ability. I will usually send them to physical therapy to develop and strengthen their core muscles if needed to a 5/5 strength. Then I turn them on their stomach in a prone position and palpate direct pressure on the posterior spinous process on the left and right side all the way down to the sacrum, for degenerative facets or discs. When prone, a reverse straight leg raise can divulge an L2-L3 or L3-L4 disc or just tight quadriceps muscles, which in older people can be a source of anterior thigh pain because of lack of flexibility.
This constitutes the basic simple examination of the lower back following a reasonably detailed history from the patient.
