hi I'm dr. ball deep saying I'm an
internist here at Stanford and today
we're going to talk about the physical
exam portion of a patient presenting
with low back pain given that most low
back pain originates from the lumbar
vertebral area where the Peris - muscle
we're going to be focusing primarily on
the musculoskeletal portion of the exam
today but at the end we will review some
can't-miss diagnosis to round out the
differential so today Steve is going to
be joining us to help us demonstrate
some key aspects of the physical exam
we're going to try to focus on four
specific areas inspection palpation some
key provocative tests and end with the
neurological exam let's start with
inspection so Steve if I can have you
stand this way first thing you want to
notice is the contour of the spine
focusing on kyphosis any caiaphas or
lumbar lack of lumbar lordosis as those
can contribute to low back pain next
you'll have the patient bend over Steve
if I can have you bend over looking for
any scoliosis in which case you will
notice that one side of the spine may be
raised in comparison to the other side
next we'll move to the palpation portion
so try to focus on two areas and we're
going to palpate either push or tap
directly on the spine looking for
tenderness specifically and then start
to place some pressure on the Peris -
muscles to differentiate potentially a
spinal cause of pain versus a pair of
spinal cause of pain in this portion we
are going to review some key provocative
portions of the exam starting with the
tripod sign so while the patient is
remaining seated we're going to try to
lift the affected side in this case
let's say the patient is describing
radicular plane down the right leg so by
elevating the right leg if the patient
has pain note that that both arms
thin hence causing a positive tripod
sign next to confirm our finding with
the tripod sign we will proceed with the
straight leg sign elevate the affected
side to between 30 and 60 degrees beyond
60 degrees it may be a false positive as
you elevate the leg you should elicit
pain if someone has some evidence of
significant lombardi kalapa the-- on the
affected side then to confirm that you
can also drop the foot by 15 degrees and
dorsiflex foot confirming our positive
straight leg sign next we're going to be
doing the femoral stretch test the
femoral stretch test is very helpful
when considering a diagnosis of lumbar
radiculopathy in the l2 to l4 region
this the straight leg and tripod signs
are very helpful in l5 and s1
radiculopathy but if you suspect l2 to
l4 which is much rarer you would take
the leg bend the knee grab the base of
the knee and extend the leg up if the
patient complains of pain on the
anterior thigh and responds to this
maneuver is very suggestive of l2 to l4
radiculopathy in patients with low back
pain typically conservative treatment is
very commonly prescribed as most
patients improve with that however in
some cases if the patient has a
concerning history for more serious
radicular pain you may want to proceed
with a neurological exam as this may
result in further imaging or
consultation we are now going to be
focusing on the neurological exam
focusing primarily on three key areas
the motor exam a sensory exam and
reflexes given that the vast majority of
lumbar radiculopathy comes from three
levels l5 l4 l5 and s1 we will be
focusing most of our time on those areas
starting with the motor exam we're going
to focus on three areas l4 l5 and s1 to
test l4 we're going to have the patient
bend the knee and kick out there by 10
setting up the quadriceps checking for
l4 you want to always compare to the
opposite side go ahead Steve and kick so
you can compare both sides to make sure
they're equal next we're going to
proceed to l5 in which the case the
patient will dorsiflex
foot and the big toes comparing both
sides putting quite a bit of pressure in
order to listen any subtle difference
between the two sides finally we'll end
with s1 where we have the patient
plantar flex or push down as hard as
possible on both hands again comparing
both sides to see if there's any s1
discrepancy to confirm the findings on
the neurological exam we just
demonstrated will now assess l5 and s1
in a different way so what I'll do is
I'll have Steve walk across the room
walking on his heels looking at both
toes to see if one foot is dropped go
ahead Steve if there's an l5 weakness
we'll see that one foot will drop in
relation to the other next to assess for
s1 we'll have Steve stand on both toes
and walk across the room looking at the
heels to see if one heel is dropped in
comparison to the other if that is the
case is suggestive of a significant
weakness of s1 next we're going to be
going to the sensory portion of the exam
focusing on l4 l5 and s1 to start with
we will try to take a monofilament or
pin and try to distinguish if there's
any numbness on one side as compared to
the other in the case of l4 we're going
to be focusing on the anterior lateral
aspect of the thigh looking for any
discrepancy in the dermatomes patient
we'll say that one side is number than
the other moving to l5 the space between
the first and second toe again looking
for any discrepancy in the dermatome
patient would describe numbness and
finally ending with s1 which is the
lateral aspect of the foot next we're
going to be moving to the reflex portion
of the exam focusing again on l4 l5 and
s1 for l4 we would bend the legs
patient's legs slightly while they're
lying down and while their leg is very
relaxed try to elicit a patellar tendon
reflex next for l5 put your fingers
across the medial hamstring trying to
elicit the medial hamstring reflex
looking forward the hamstring to
activate above your hand
and finally for s1
we would bend the leg dorsiflex the foot
and again with the patient relaxed tap
the Achilles looking for a jerk in the
Achilles tendon
if the neurological exam is normal
usually you don't need to proceed to
advanced imaging such as MRI we can
usually start with simple treatments
such as anti-inflammatories and physical
therapy and see how the patient does if
the patient continues to do poorly
patients symptoms persist we can
typically have the patient come back in
six to eight weeks to reassess and
thereby decide if we need to do further
testing later finally while by far in a
way issues with the vertebra or muscles
are the major causes of low back pain be
sure to look for these can't miss
diagnosis malignancy infections such as
osteomyelitis or epidural abscess where
patients may present with signs and
symptoms of infection inflammatory
arthritis and lastly or very rarely
other areas that can mimic low back pain
such as prostatitis of the confirmatory
disease kidney stones and they order
gander ISM or gastrointestinal disease
that concludes our video on the low back
examination I would like to thank Steve
for helping us demonstrate key aspects
of the low back exam today for future
videos please visit the Stanford 25
website the preceding program is
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the Leland Stanford junior University
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