Neurological examination of the legs after back pain
PLAB 2 practice station

The task

You are a doctor in a clinic. Mr Dominic Rossi, aged 47, has had low back pain with pain down his right leg for two weeks and now trips on his right foot. He is sitting on the couch in shorts. Perform a neurological examination of his lower limbs. Say aloud what you are doing at each step. The examiner will report the findings when you say what you are doing, so describe each step as you go. At the end, summarise your findings and say what you think is going on and what you would do next.

What this station tests

• Always screen for cauda equina syndrome in back pain with leg symptoms: saddle numbness, bladder and bowel changes.
• Compare left and right at every step of tone, power, reflexes and sensation.
• Foot drop with weak inversion and hip abduction suggests an L5 root lesion; a common peroneal nerve palsy spares them. New significant weakness needs urgent imaging and specialist discussion.
• Test saddle sensation and ask about sphincter function even if the patient does not volunteer symptoms.
• Give specific safety-netting for cauda equina symptoms.

Sources for the clinical content

• NICE NG59: Low back pain and sciatica in over 16s: assessment and management
• GIRFT: National pathway for suspected cauda equina syndrome

An original practice scenario with invented patients. Not an exam question.

Practise next

• Cardiovascular examination in a breathless man
• Respiratory examination in a woman with cough and fever
• Abdominal examination with a painful groin lump
• Examination of a swollen painful knee
• Thyroid examination in a woman with weight loss