Section | Description | Scoring Criteria |
1. Patient Introduction & Communication | ||
Greeting | Introduce yourself, confirm patient's name and age, explain purpose of examination. | Required for completion |
Consent | Obtain verbal consent for physical examination. | Required for completion |
Explanation | Explain each maneuver before performing, especially those likely to cause discomfort. | Required for completion |
2. History Taking | ||
Location and Radiation of Pain | Assess for sharp, shooting pain radiating down the leg, often below the knee, following a dermatome. | Points awarded for correct identification |
Onset, Duration, and Progression | Clarify onset (sudden, e.g., after lifting), duration, and progression. | Points awarded for correct identification |
Character of Pain | Identify electric-shock-like pain, worsened by coughing, sneezing, or bending. | Points awarded for correct identification |
Associated Symptoms | Document neurological deficits (numbness, tingling, or weakness along L4 or L5). | Points awarded for correct identification |
Red Flags | Check for bowel/bladder dysfunction, night pain, weight loss, fever (suggestive of cauda equina syndrome). | Required for completion |
3. Physical Examination | ||
Inspection | ||
Posture and Alignment | Observe spine for kyphosis, lordosis, scoliosis, and check iliac crests for symmetry. | 10 points for correct explanation |
Gait | Instruct patient to walk; observe for asymmetry, limping, or guarded movement. | 10 points for correct explanation |
Palpation | ||
Iliac Crest | Palpate superior border of iliac crest on both sides to confirm alignment. | 10 points for correct explanation |
Spinous Processes | Palpate L4-L5 spinous processes for tenderness or step-off deformities. | 10 points for correct explanation |
Paraspinous Muscles | Palpate paraspinous muscles bilaterally to assess for spasm or tenderness. | 10 points for correct explanation |
Range of Motion (ROM) | ||
Flexion, Extension | Ask patient to bend forward (flexion) and lean back (extension), noting any pain or limitation. | 10 points for correct assessment |
Rotation, Lateral Bending | Assess rotational and lateral bending movements, noting pain provocation. | 10 points for correct assessment |
Provocative Tests | ||
Straight Leg Raise Test (SLRT) | Positive if pain radiates down the leg at 30-60 degrees of hip flexion. | 20 points for two correctly performed tests |
Contralateral SLR | Perform on unaffected leg first; pain in symptomatic leg suggests severe HNP. | 20 points for two correctly performed tests |
Lasegue Maneuver | Positive if dorsiflexion of foot during SLRT increases pain, indicating root tension. | 20 points for two correctly performed tests |
Bowstring Test | Flex knee slightly during SLRT and apply pressure to sciatic nerve; positive if pain reproduced. | 20 points for two correctly performed tests |
Tripod Sign | Ask patient to extend knee while seated; discomfort suggests root compression. | 20 points for two correctly performed tests |
Neurological Examination | ||
Motor Testing | L2 (hip flexion), L3 (knee extension), L4 (ankle dorsiflexion), L5 (great toe extension), S1 (plantar flexion). | 7 points for correct motor testing |
Sensory Testing | Test dermatomes: L4 (medial leg), L5 (dorsum of foot), S1 (lateral foot). | 6 points for correct sensory testing |
Reflexes | Assess Patellar Reflex (L4) and Achilles Reflex (S1); diminished reflex may indicate root compression. | 6 points for correct reflex testing |
Tests for Differential Diagnosis | ||
Hip ROM | Differentiate hip pathology from radicular pain. | 6 points for correctly performed test |
Anvil Test | Strike heel lightly to check for hip or femoral pathology. | 6 points for correctly performed test |
Rolling Test | Roll leg to differentiate hip pathology from spine pathology. | 6 points for correctly performed test |
Patrick’s (FABER) Test | Evaluate for SI joint involvement. | 6 points for correctly performed test |
Pelvic Rock Test | Iliac compression test for SI joint pain. | 6 points for correctly performed test |
Femoral Stretch Test | Useful for high lumbar (L2-L4) root involvement; check if patient experiences pain. | 6 points for correctly performed test |
Diagnosis Considerations | ||
Provisional Diagnosis | Identify HNP with L4 or L5 root compression based on findings. | Required for passing |
Signs of Cauda Equina Syndrome | Check for urinary difficulty, saddle anesthesia, bowel/bladder incontinence, and bilateral lower limb weakness. | Required for passing |
Passing Criteria | Minimum Required Score: 60 points | Total Points Possible: 100+ |
1. Patient Introduction & Communication
Introduction: Greet the patient warmly. Verify their identity by name and age, and explain each step of the physical exam to ensure understanding and cooperation.
Consent: Obtain consent, stating the purpose of assessing their back pain and explaining that some maneuvers may provoke pain.
Explanation: Before each maneuver, explain what will be done and why it’s essential, especially if discomfort is expected.
2. History Taking
Location and Radiation of Pain:
HNP: Sharp, shooting pain radiating down the leg, often below the knee and following a specific dermatome. Commonly unilateral (e.g., right leg pain).
Onset, Duration, and Progression:
HNP: Sudden onset, often following activities involving heavy lifting or a twisting motion.
Key History Point: For example, "30-year-old male, leg pain following lifting heavy objects" suggests HNP.
Character of Pain:
HNP: Electric-shock-like or sharp pain exacerbated by activities that increase intraspinal pressure, such as coughing, sneezing, or bending.
Associated Symptoms:
Neurological Deficits: Numbness, tingling, or weakness following the path of the compressed nerve (usually L4, L5, or S1 roots).
Red Flags:
Important to assess for signs like bowel/bladder dysfunction, night pain, significant weight loss, and unexplained fever, which may indicate serious pathology (e.g., cauda equina syndrome).
3. Physical Examination
Inspection:
Observe posture and alignment. Check for spinal curvatures (kyphosis, lordosis) and assess gait for asymmetries.
Pelvic Symmetry: Ensure the iliac crests are level and observe gait for limping or guarded movement.
Palpation:
Palpate spinous processes and paraspinal muscles for tenderness or spasm, especially in the lower lumbar area.
Check Step-Off Deformities: Feel along the spine for any vertebral misalignment, which may indicate spondylolisthesis.
Range of Motion (ROM):
Flexion and Extension: HNP patients typically experience increased pain with flexion, whereas extension may be limited but less painful.
Rotation and Lateral Bending: Evaluate for pain provocation, particularly during flexion.
Special Tests:
Straight Leg Raise Test (SLRT):
Essential for HNP. Positive if pain radiates down the leg at 30-60 degrees of hip flexion.
A classic sign for lumbar disc herniation, especially involving L5 or S1 roots.
Crossed Straight Leg Raise (Contralateral SLR):
Pain induced in the symptomatic leg when the opposite leg is raised suggests severe HNP.
Lasegue Maneuver (foot dorsiflexion test):
Exacerbates pain if there is nerve root compression, specifically when dorsiflexing the foot during SLR.
Bowstring Test:
Confirms sciatic involvement by reproducing pain when applying pressure on the sciatic nerve in a flexed knee position.
Neurological Examination:
Motor Testing:
L2: Hip flexion
L3: Knee extension
L4: Ankle dorsiflexion
L5: Great toe extension
S1: Plantar flexion
Sensory Testing:
Test for numbness or reduced sensation in relevant dermatomes:
L3: Medial knee
L4: Medial leg
L5: Dorsum of the foot
S1: Lateral foot
Reflexes:
Diminished Patellar reflex (L4) or Achilles reflex (S1) may indicate root compression.
4. Differential Diagnosis
Primary Diagnosis:
Herniated Nucleus Pulposus (HNP): Unilateral, dermatomal pain extending below the knee, positive SLR, and neurological deficits.
Secondary Differential:
Spinal Stenosis: Pain worsens with extension and prolonged standing; relieved by sitting or bending forward (pseudoclaudication).
Mechanical Back Pain: Pain localized to the back, improved with rest, without radicular symptoms.
Others:
Cauda Equina Syndrome: Incontinence, saddle anesthesia, bilateral leg weakness—requires urgent referral.
Infectious Causes: Fever, recent infection, IV drug use, or immunocompromised status (e.g., osteomyelitis, discitis).
Neoplastic: Persistent night pain, unexplained weight loss, history of cancer.
5. Diagnostic Investigations
MRI of the Lumbar Spine:
HNP: Visualizes disc herniation impinging on nerve roots, confirms diagnosis and level of compression.
X-ray of the Lumbar Spine:
Useful to rule out vertebral fractures or degenerative changes.
Electromyography (EMG):
May assist in assessing nerve root involvement if symptoms are unclear or inconclusive.
CT Myelogram:
Considered if MRI is contraindicated or if additional details about spinal canal anatomy are needed.
6. Management Plan
Conservative Management:
Pain Management: NSAIDs, muscle relaxants, or short-term use of opioids in severe cases.
Physical Therapy: Emphasis on core strengthening, lumbar stabilization, and gentle stretching.
Activity Modification: Advise against heavy lifting or activities that exacerbate pain.
Interventional Management:
Epidural Steroid Injections: For patients unresponsive to initial conservative treatment, targeting inflammation at the affected nerve root.
Surgical Intervention:
Microdiscectomy: Indicated for severe or persistent pain beyond 6 weeks or progressive neurological deficits.
7. Patient Education and Follow-Up
Education:
Explain the nature of HNP and emphasize the importance of adherence to therapy and activity modifications.
Advise on proper lifting techniques and ergonomic adjustments to minimize future strain.
Follow-Up:
Schedule regular follow-up appointments to monitor symptoms and recovery.
Educate the patient to report any worsening symptoms, particularly those suggestive of cauda equina syndrome (e.g., bowel/bladder dysfunction).
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