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An “Ow-wee” in the Back, Grand Rounds, and No Reflex Hammer to Be Found :

November 19, 2020

Back pain. There is always someone complaining of back pain, whether a neighbor, a colleague, or a family relative.

Back pain. There is always someone complaining of back pain, whether a neighbor, a colleague, or a family relative. I never understood the significance of back pain until one memorable afternoon when a spasm shot through my lower back as I kicked a box to the side while carrying another box. I now have profound respect for back pain. As others will readily agree, back pain can make simple everyday tasks very, very hard to do.

This month Drs Lamb and Brenner discuss back pain in children and adolescents (10.1542/pir.2019-0051).  In their introduction, they mention that back pain is more common than was once thought, but thankfully most causes of back pain in children and adolescents are “benign, self-limited, and idiopathic.”  Their review provides practical information on how to evaluate back pain. I particularly enjoy this article because it reminds me when I presented cases of children and adolescents with back pain at Grand Rounds—cases that it took me a span of 10 years to collect.

In that talk, I presented three children: one who turned out to have a spinal ependymoma, another who had Guillain-Barre Syndrome, and a third who developed acute lymphocytic leukemia.  I also talked about six adolescents with either spondylolysis, spondylolisthesis, Scheuermann's disease, discitis, myositis, or a herniated lumbar disc.  According to Drs Lamb and Brenner, to make my Grand Rounds complete I needed to add apophyseal ring fracture, sacroiliitis, ankylosing spondylitis, and mechanical back pain.

When it comes to evaluating a child or adolescent with back pain, Drs Lamb and Brenner stress the importance of a thorough musculoskeletal examination. They write, “All patients, including infants, should have a neurologic exam that assesses their muscular tone, sensation, and deep tendon reflexes.” This mention of deep tendon reflexes brings me back to the case of the child with Guillain-Barre syndrome who complained of an “ow-wee” in her back. Because her presentation was unusual, we filmed her physical exam. During the filming of the exam, I realized I did not have a reflex hammer, so I quickly improvised by using the edge of the head of my stethoscope as a reflex hammer. I could not elicit deep tendon reflexes in either knee, probably the first clue that the young girl had an atypical form of Guillain-Barre syndrome in which back pain was the chief complaint.

When I showed the video of my examination of the child with back pain and absent deep tendon reflexes during Grand Rounds, the pediatric neurologist in the audience immediately piped up that the absence of reflexes was, of course, no surprise since the stethoscope as reflex hammer has questionable worth. Laughter aside, several general pediatricians then voiced their strong views that the stethoscope could and did serve as an adequate, readily available, and conveniently present reflex hammer.  Unlike the stethoscope, the reflex hammer is frequently absent in many a patient’s room, let alone on a pediatrician’s person.

While writing this blog, on a whim, I typed the search phrase “stethoscope as reflex hammer” in PubMed. In 2014, in a letter to the journal Surgery, Ologunde and Rabiu wrote, “As early as 1879, the great British neurologist Sir William Gowers suggested the stethoscope to have a role in the neurologic examination as a mock tendon hammer.”1 I wished I had known that years ago when I gave that Grand Rounds.

But I digress. Back pain does occur in children and adolescents. Drs Lamb and Brenner give an excellent review on this topic and remind everyone to do a thorough musculoskeletal exam when evaluating patients with back pain.

And if the reflex hammer is missing when examining the patient, go ahead and use the stethoscope.


  1. Ologunde R, Rabiu R. Stetho-hammer: a not-so-novel aid in the neurologic examination. Surgery. 2014 Nov;156(5):1286-7. doi: 10.1016/j.surg.2014.04.040. Epub 2014 Jun 27.PMID: 24981587
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