How to Examine the Lumbar Spine

spine exam
Adam Berry / Stringer Getty Images 

Symptoms of pain or discomfort in the legs or low back may be a sign of a problem with the lumbar spine, and a reason to examine that part of your body. When evaluating for lumbar spine conditions, your physician will evaluate a series of functions to determine the location and source of your problem.

Most physicians take a very systematic approach to evaluation of lumbar spine problems. While there is undoubtedly variation from physician to physician, the basic steps of the lumbar spine examination are typically very similar.

Depending on your symptoms and your clinical findings, the focus and depth of the examination may also vary.

A few important points before we get into the details of examining the lumbar spine:

  1. First, a complete examination and determination of the source of pain may take more than one visit to your clinician. Typically, the goal of an initial evaluation is to ensure that there are no signs of a lumbar spine problem that could cause an emergency situation. When the situation looks to be non-emergent, the goal often becomes to control symptoms rather than delving into an extensive evaluation.
  2. Second, examining the lumbar spine requires evaluation of not only the lower back segment of the body, but also the important nerves that extend from this region down the lower extremities. It is that reason why you're doctor may spend some time evaluating strength, sensation, and reflexes in the lower extremities.

    Red Flags for More Serious Problems

    As stated, when initially evaluating a lumbar spine problem there are a few conditions that could be more serious, and these emergency surgical situations and need to be identified immediately. These include conditions such as infection, tumors, and severe nerve compression.

    While these conditions are relatively rare, your doctor will ask you questions and examine you to ensure there are not signs of these conditions. These so-called "red flags" for lumbar spine conditions include:

    • Recent fevers, weight change, or night sweats
    • History of cancer that can migrate to bone
    • Pain that is unremitting at rest or awakens from sleep
    • Incontinence or urinary retention
    • Recent trauma

    These 'red flag' signs will guide your clinician to focus their examination and possibly obtain further tests to evaluate for these serious conditions that could be present. It's important to realize that just because you have a fever, it does not mean that your back pain is an emergency. However, these signs can be associated with some serious conditions, and they are signs that should trigger a more in-depth evaluation.

    Examining the Spine

    Having a systematic approach to examination helps to ensure that your examiner will not overlook important details. The normal steps to examining the lumbar spine include: inspection, palpation, mobility, nerve function, and special tests. Each of the steps can be evaluated with a few simple steps, and if abnormalities are noted, a more detailed investigation can take place.

    • Inspection: Inspection includes evaluation of the appearance of the lumbar spine. This can include evaluation of the alignment from both the front and the side of the patient. Evaluation should take place of the bare skin to evaluate for any abnormalities or evidence of injury.
    • Palpation: Palpation means to touch the body. Your examiner can feel for any masses or other abnormalities around the lumbar spine and lower abdominal region. In addition, palpation should evaluate for any specific region that is tender to touch.
    • Mobility: Mobility of the lumbar spine can be evaluated by asking the patient to bend forwards, backwards, twist to each side, and lean to each side. In addition, most examiners will want to evaluate for any possible gait abnormality that can be indicative of problems with nerve function.
    • Nerve function: In general, your examiner will evaluate three functions of the nerves. First, the strength of the various muscles of the lower extremity. Second, the sensation throughout the lower extremities. Third, the function of your reflexes, most often at the knee and at the ankle, although there are other reflexes that can also be evaluated. Weakness of muscles, abnormalities of sensation, and asymmetric reflexes can all be indicative of abnormal nerve function.
    • Special tests: There are number of special tests that your examiner may perform. These tests may include special tests of nerve function and signs of nerve irritation. The most commonly performed test is called a straight leg raise test.

    Ordering Tests

    Ordering imaging studies is generally not necessary for the initial treatment of low back pain. When there are concerning symptoms for a serious underlying condition, a test may be ordered to evaluate for one of these conditions. However for back pain thought to be coming from a more typical source (muscular strain, disc abnormalities, arthritis, etc.), early testing is generally not helpful, and in many cases can lead to more invasive treatment than might otherwise be necessary.

    When a test is ordered, your physician may order one of several different tests. One is not necessarily better than another, but in specific situations one may be more helpful. Many people I see about back pain want MRIs. MRIs are often a helpful test, but not in all scenarios. In addition, MRIs need to be carefully interpreted, because they often show some findings that may be helpful, and others that have little to do with the source of discomfort. Being led astray by following test results without putting those into the context of the examination and findings listed above can lead to inappropriate or unnecessary treatments.

    A Word From Verywell

    It's important to acknowledge that nothing described so far is likely to make you feel any better or relieve painful symptoms. While ensuring no serious conditions are occurring and trying to define the problem are important steps, the reality is that treatment is what people are looking for. Often, the treatment is not dependent on the exact diagnosis. For most causes of back pain, treatment begins with the same steps regardless of whether the problem is a disc issue, a muscle strain, or something else. Only in unusual circumstances that usually involve the 'reg flag' signs will the treatment end up being something else.


    Choosing Wisely® is an initiative of the ABIM Foundation. © 2017

    Chou R, et al. Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. "Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society." Ann Intern Med. 2007 Oct 2;147(7):478-91.

    Forseen S, Corey A. "Clinical decision support and acute low back pain: evidence-based order sets". J Am Coll Radiol. 2012 Oct;9(10):704-12.