Examination

Assessment

Subjective Examination

  • Mechanism of injury (if one)
  • Initial Symptoms
  • Region of Pain
  • Presence of Lower Limb Symptoms – Pins and Needles, Numbness, Pain, Weakness
  • Initial dysfunction and management
  • Progression of Symptoms
  • Specifics NOW:
    • Aggravating and Easing Factors
    • Pain behaviour (ie progression during day, presence of resting pain)
  • SPECIAL QUESTIONS
    • Bowel / Bladder Dysfunction (Incontinence, retention, offensive urine, constipation)
    • Unexplained Loss of appetite, loss of weight
    • History of recent or current illness
    • History of IV drug use
  • Yellow Flags

Objective Assessment

  • Observations – HR, BP, TEMP (IF INDICATED)
  • Neurovascular status
  • Local changes (?dermatomal rash)
  • Bed Assessment:
    • SLR / PKB
    • Neurological Ax – Tone, Power, Reflexes, Sensation
    • Palpation
  • Standing Assessment
    • Posture / presence of list (pelvic shunt to side)
    • Lumbar Range Of Motion (If Not Particularly Irritable)
    • Flexion / Extension / Lateral Flexion / Rotation
  • Special Tests
    • Waddell’s Signs

Neurological Examination

For videos, go to Neurological Examination

Neuromeningeal Testing

  • This involves stretching the tissues that protect the central and peripheral nervous system
  • If there is tethering of neural structures (eg from a nerve root compression, scar tissue from an injured muscle or laceration sticking to peripheral nerves), stretching of these structures usually reproduces pain
  • A positive test does not necessarily mean that the pain is coming from compression of nerve roots – it merely indicates that SOME component of the pain is relating to the neuromeningeal structures

Prone Knee Bend

  • Prone knee bend stresses the anterior travelling nerve fibres
  • Begin by flexing the patient’s knee to 90 degrees
  • Extend the patient’s hip from the bed until they tell you to stop, significant pain is elicited or there is no further range possible
  • A strong stretch is normal – reproduction of the patient’s pain is abnormal
  • Measure the angle at which symptoms are first produced

Straight Leg Raise

  • The straight leg raise test for LBP is PASSIVE (active straight leg raising pulls anteriorly on the lumbar spine via Psoas and will reproduce lower back pain in most patients).

  • Straight leg raise stresses the posteriorly travelling nerves (which terminate in the sole of the foot)

 

 

  • Begin by dorsiflexing the patient’s foot

  • Keeping the knee straight, lift the patient’s leg from the bed until they tell you to stop, significant pain is elicited or there is no further range

  • A strong stretch is normal – reproduction of the patient’s pain is abnormal
  • Measure the angle at which symptoms are first produced
  • Move the ankle into plantarflexion and note any changes in pain
  • SLR is highly sensitive for herniated discs (0.92), but of variable specificity (0.1 to 1)
  • Crossed SLR (eg SLR on L causes pain on R) shows high specificity (0.9) but low sensitivity (0.28)
    * Surgical population

Power

  • When testing power, instruct the patient that you need them to push as hard as they can (even if it is painful) against your resistance.
  • Use your body positioning to make it as easy as possible for yourself – resist as distally as possible
  • For scoring, use the Oxford grading system :
Oxford GradeDescriptor
0No signs of activity
1Flicker of activity, no movement
2Full active range of motion, across gravity
3Full active range of motion, against gravity
4Moderate resistance
5Maximal resistance

Myotomes

MovementNerve Root Segments
Hip flexionL2/3
Hip extensionL4/5
Hip adductionL2/3
Hip abductionL4/5
Knee extensionL3/4
Knee flexionL5/S1
Ankle DorsiflexionL4/5
Great toe extensionL5
Ankle plantarflexionS1/2

 

Reflexes

  • Technique
    • Patient must be relaxed
    • Grip on hammer should be loose (hammer should bounce when striking tendon)
    • Compare to normal side (or knowledge of “normal”)
  • Abnormalities
    • Hypoactive (nerve root)
    • Hyperactive (cord / CNS)
  • Grading
    • No response
    • + lower than normal
    • ++ normal
    • +++ brisk
    • ++++ very brisk
    • Clonus

Dermatomes

Likely sensory changes with nerve root lesions

Likely path of radicular pain

 

Yellow Flags

Red Flags

  • Infection
    • Fever / other signs of infection
    • Underlying disease process, immunosuppression, penetrating wound
    • History of IV drug use
  • Fracture
    • History of Trauma (or minor trauma if >50 and with history of OP +/- prolonged steroid use)
  • Tumour
    • Past History of malignancy
    • Age >50
    • Failure to improve with Rx
    • Unexplained LOW
    • Pain at multiple sites +/- resting pain
  • AAA
    • Absence of aggravating factors