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OSCE Orthopedics: Back Pain - Focus on Herniated Nucleus Pulposus (HNP)

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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