Competency 3: Lumbar Spine Examination Flashcards
The lumbar vertebra lack what features seen elsewhere in the spine?
- Lack costal facets (found in thoracics)
- Lack transverse foramina (found in cervicals)
What’s found within the Intervertebral Neural Foramina?
- Spinal nerve roots
- Recurrent meningeal nerves
- Radicular blood vessels
What decreases the area of the Intervertebral Neural Foramina?
- Extension (pedicles glide toward one another)
- Arthritis
- Spurs
- Hypertrophy of posterior longitudinal ligament
- Herniation of nucleu pulposus
- Tissue congestion/edema
- Inflammation
- Perineural edema
Function of the Intervertebral Discs; what’s found inside; what side is thicker and why is this significant?
- Dissipate heavy loads
- Nucleus pulposus (soft mucoid central core) surrounded by annulus fibrosis (concentric lamellae of collagenous fibers)
- Thicker anteriorly, thinner posteriorly (clinically significant for herniations –> more likely to herniate posteriorly)
Lumbar nerve roots exit where in relation to their named vertebra?
Exit below the named vertebra
What are the pedicles of the lumbar vertebra?
Connect posterior elements to vertebral body. Protect from significant disc herniation
What is Zygapophyseal joint tropism; how is it assessed?
- Most common lumbar congenital abnormality
- Articular pillars on one side of vertebral unit are twisted so plane of joint does not match that of other side
- Assessed w/ asymmetric muscle tensions and altered spinal motions
The height of the iliac crests lies in the same plane as which lumbar SP?
L4 spinous process
What does the spinal canal contain; where does spinal cord end; what does it terminate as?
- Contains dural tube, spinal cord, origins of spinal nerves down to approximately L1-L2 or L2-L3 where spinal cord ends
- Below L1-L2 or L2-L3, contains cauda equina and filum terminalis
What are the etiologies of a slumped over appearance when observing lumbar?
- Psychiatric considerations (i.e., depression)
- Muscle spasm (i.e., psoas)
- Reactive effort (relief of pressure from condition impinging lumbar nerves in intervertebral foramen)
What are the etiologies of an erect stance appearance when observing lumbar?
- Protecting herniated disc or effects of spinal stenosis
- Especially consider with muscle weakness, reflex changes, or muscle atrophy
If you observe a gait that is “listing” of trunk to one side what should you think about?
- Disc herniation
- Muscle weakness - especially gluteus medius
A shuffling or fenestrated gait is seen with what disease?
Parkinson’s disease
When palpating over the spinous processes why do we feel for “step offs?”
Spondylolisthesis (forward slippage of vertebra which may compress spinal cord)
How can we do palpation for Sciatic nerve tenderness; what nerve roots does it contain and where is it found?
- Lateral recumbent w/ hip flexed
- Largest nerve in body L4-S3
- Lies midway between the greater trochanter and the ischial tuberosity (sciatic notch)
When inspecting and evaluating the skin in the lumbar region what are we looking for?
- Dermatologic conditions/rashes may occur w/ various conditions including infection, reactive processes and spondyloarthropathies
- Birth marks, port-wine stains, lipomas
- Patches of hair (Spina Bifida)
- Cafe-au-lait spots (discolored patches of skin), skin tags, or fibrous tumors (common in neurofibromatosis)
Herniated intervertebral discs are most common at what lumbar levels?
- L5-S1
- L4-L5
Normal ROM for lumbar flexion and muscles involved?
- 40-90°
- Psoas, Abdominal muscles
Normal ROM for lumbar extension and muscles involved?
- 20-45 °
- Deep intrinsic back muscles, Quadratus Lumborum
Normal ROM for lumbar rotation and muscles involved?
- 3-18°
- Abdominal muscles
- Intrinsic muscles of back
Normal ROM for lumbar sidebending and muscles involved?
- 15-30°
- Abdominal muscles
- Intrinsic back muscles
What is the Straight Leg Raise (Lasègue) Test; positive test; what does it indicate?
- Pt is supine, while doc passively flex patient’s ipsilateral hip w/ knee extended. Add dorsiflexion to increase dural tension in low lumbar and high sacrals
- (+) test is presence of worsening or radicular pain radiating into the ipsilateral leg, especially between 30-60° and worse w/ dorsiflexion
- Tightening or discomfort in buttocks/hamstrings is common and is NOT a positive test
Indicates: lumbosacral radiculopathy (usually herniated disc) and/or sciatic neuropathy
If doing the straight leg raise test and there is a positive sign at >70° or laterally at >15° what may this indicate?
- >70° more likely mechanical low back pain due to muscle strain or joint disease
- Laterally at >15° could indicate IT band contracture
What makes the diagnosis of sciatica five times more likely?
Ipsilateral calf wasting and weak dorsiflexion
Which test increases the specificity of the straight leg raise test?
Contralateral (crossed) straight leg raise test
What is the Contralateral (Crossed) Straight Leg Raise Test; what is positive test; what does it indicate?
- Pt is supine, while doc passively flex patient’s contralateral hip w/ knee extended
- (+) test: presence or worsening of radicular pain radiating into the contralateral leg, especially between 30-60°
- Indicates: Lumbosacral radiculopathy (usually from a herniated disc) and/or sciatic neuropathy
What is Hoover’s Sign; positive test; indicative of what?
- Pt is supine. Hold hand under the heel of unaffected leg. Ask pt to try and flex the affected (weak) leg against slight resistance while maintaining extension at knee (straight leg). If honest effort is made the doc should feel the unaffected leg’s heel pushing down as they attempt to raise the affected leg.
- (+) Test: No downward force of the unaffected leg as they are “attempting” to lift the affected leg
- Indicates: functional weakness (“conversion disorder”) or malingering of the patient
What is the Gaenslen Test; positive test; indicates what?
- Pt is supine. Flex one hip and knee to chest while simultaneously extending opposite hip (off side of table)
Alternative: lateral recumbent. Pt flexes lower hip and holds, doc then extends top hip. Manuever stresses both sacroiliac joints
- (+) test: Posterior pelvic pain
- Indicates: Sacroiliac joint dysfunction or pathology
What is the Valsalva Test for the lumbar region; positive test; indicates what and what type of pain is more indicative of true radiculopathy?
- Pt holds breath and bears down, which increases intrathecal pressure.
- (+) Test: Sciatica symptoms (a sharp or bruning pain radiating down the posterior or lateral aspect of the leg, usually to the foot or ankle)
- Indicates: Sciatica (Sciatic nerve compression or irritation)
- Pain radiating below the knee is more likely to represent true radiculopathy than proximal leg pain
What is the Stork Test; positive test; indicates and what if bilateral?
- Pt standing. Have pt flex hip and knee of one leg. Stabilize pt’s iliac crests, if needed, and have them lean back extending the lower back
- (+) Test: Pain in lower back as it stresses the posterior elements of the spine on the ipsilateral side
- Indicates: Possible pars defect/stress fracture
* If bilateral, increased risk of spondylolisthesis
What is Cauda Equina Syndrome?
Condition of spinal nerve root compression usually by massive disc protrusion, fracture/trauma, or tumor that results in bowel/bladder dysfunction
There is no one single test for Cauda Equina Syndrome, but which clinical features require an investigation?
- Low back pain (usually first sx present in 90% cases). Can precede neurologic symptoms by weeks in cases not secondary to immediate trauma
- Bowel/bladder dysfunction (overflow incontinence)
- Sensory loss of perinenum (“Saddle Anesthesia”) and decreased anal sphincter tone
- Bilateral sciatica and leg weakness
If Cauda Equina is present what is required?
Emergent management and surgical decompression within 48 hours, or permanent neurologic damage can remain
What is Spina Bifida Occulta?
- Small split in vertebra, NO spinal cord protrusion
- Asymptomatic. Usually incidental finding on radiograph
- Most common at L5-S1
- May find coarse patch of hair or birthmark on dimple
What is Meningocele?
- Meninges forced out between vertebra
- Surgically repaired, usually no neurological damage
What is Myelomeningocele?
- Most common type
- Unfused portion of spinal cord protrudes through opening
- Very severe (permanent) neurologic complication
What is a normal Ferguson’s Angle on Lumbar X-ray?
Normal = 30-40°
What condition is shown here?
- Spondylolysis
- Defect or fracture in the pars interarticularis of the vertebral arch
*Scotty Dog*
What condition is shown here?
- Spondylolisthesis
- Anterior displacement of a vertebral body
What is Spondylosis?
- Osteoarthritis
- Age-related wear and tear of the spine
What is shown here?
Disc herniation
What areas do the sensory dermatomes of L1-L5 cover?
- L1 Pubic hairline
- L2 Upper medial thigh
- L3 Medial knee
- L4 Patella, medial calf
- L5 Great toe
What lumbar nerve roots for hip flexion?
L2-L4
What lumbar nerve roots for hip abduction and adduction
Abduction: (L4-L5, S1)
Adduction (L2-L4)
What lumbar nerve roots for knee flexion and extension?
Knee flexion: L4-5, S1-S2 - hamstrings
Knee extension: L2-L4 - quadriceps
What nerve roots and muscle for ankle dorsiflexion and plantarflexion?
Dorsiflexion: L4-L5 - tibialis anterior
Plantarflexion: S1 - gastrocnemius
What nerve roots is the patella and achilles reflex test addressing?
Patella: L4 (L2-L4)
Achilles: S1
What is the specificity and sensitivity like of the straight leg raise and contralateral (crossed) straight leg raise test?
- Straight leg raise has high sensitivity, but low specificty
- Contralateral (crossed) straight leg raise has low sensitivity, but high specificity
