Lumbar Spine Exam

Question 1

forward flexion

Answer 1

(40°‐90°)

Primary muscles: Psoas, quadratus lumborum, abdominal m.

Question 2

extension

Answer 2

(20°‐45°)

Primary muscles: deep intrinsic (ie: erector spinae, transversospinalis)

Question 3

lateral bending

Answer 3

(15°‐30°)

Primary muscles: abdominal and intrinsic m. of back

Question 4

rotation

Answer 4

(3°‐18°)

Primary muscles: abdominal and intrinsic m. of back

Question 5

mm strength L1

Answer 5

Iliopsoas (hip flexion) – innervation from L1‐L3

Question 6

mm strength L2-L4

Answer 6

Iliopsoas (hip flexion) – innervation from L1‐L3
Quadriceps (knee extension) – Primarily L4
Hip Adductors – innervation from L2‐L3
L4 also some Hip Abduction

Question 7

mm strength L5

Answer 7

Tibialis anterior (ankle dorsiflexion) – innervations from L4‐L5
Peroneus M’s. (Ankle Eversion)
Tibialis posterior (Ankle inversion) – L5
Gluteus medius (hip abduction) – Innervations from L4, L5, S1

Question 8

mm strength S1

Answer 8

Gluteus Maximus (hip extension) – S1
Hamstrings (knee flexion) – innervation from L5‐S1
Gastrocnemius (ankle plantarflexion) – S1

Question 9

knee (patellar) reflex

Answer 9

(L2, L3, L4 Primarily)
• Patient sitting or lying down as long as knee is flexed
• Briskly tap patellar tendon just below the patella
• Note contraction of the quadriceps with extension of knee
• Hand on pt’s anterior thigh helps you feel this reflex

Question 10

the ankle (achilles) reflex

Answer 10

(S1)
• Patient seated (or lying down with hip and knee flexed with
lower leg resting across opposite shin)
• Dorsiflex the foot at the ankle
• Strike Achilles tendon
• Watch and feel for plantar flexion at the ankle
• Slowed relaxation phase of reflexes in hypothyroidism is
often easily seen and felt in the ankle reflex

Question 11

straight leg raise test

Answer 11

• Patient supine. Raise patients pt’s relaxed and straightened leg,
flexing at the hip (some sources state slight adduction and medial
rotation) then add dorsiflexion
•Ensure patient is not actively “helping” raise the leg
•Assess degree of elevation at which pain occurs, quality and
distribution of pain and effects of dorsiflexion
•Tightness or discomfort in buttocks/hamstrings can be common,
do not interpret as “radiating pain” or a positive test
• Straight leg raising results in increased dural tension in low lumbar
and high sacral levels
• A positive test (Lasègue’s sign) is the presence or worsening of
radicular pain (not just low back or hamstring) radiating into the
ipsilateral leg with straight leg raising.
• Positive signs usually occur between 30‐60 degrees (dura not
stretched until 30 degrees) though positive signs can occur at
smaller at larger degrees of hip flexion.
•>70 degrees may still represent n. Root irritation but
increase likelihood mechanical low back pain due to muscle
strain or joint disease
• Diagnostic accuracy of the Straight Leg Raise test is limited by its
low specificity (but high sensitivity) for diagnosis of radiculopathy due
to disc herniation
•Increase specificity with Contralateral (Crossed) straight leg raise
test
•Most helpful for evaluation of radiculopathy at L5‐S1

Question 12

contralateral (crossed) straight leg raise test

Answer 12

• Passive elevation (same as with Straight leg raise) of the unaffected
leg by the examiner
• Positive test is when radicular pain is produced in the affected leg
with lifting of the unaffected leg
• Test is relatively specific for radiculopathy due to disc herniation but
has poor sensitivity

Question 13

Hoover’s sign

Answer 13

• Pt. supine,hold hand under the heel of the unaffected leg
• Ask patient to try and flex the affected (weak) leg against slight
resistance while maintaining extension at knee (straight leg)
• If an honest effort is made the physician should feel the unaffected
legs heel pushing down as they attempt to raise the affected
(weak) leg by flexing at the hip
• A positive sign would be no downward force of the unaffected leg
as they are “attempting” to lift the affected leg. This indicates a
functional weakness (“conversion disorder”) or malingering of the
patient

Question 14

Thomas Test

Answer 14

Patient tested in supine position with buttocks towards end of
table
 Flex both hips and knees to chest (flattens lumbar lordosis and
stabilizes pelvis)
 Drop the affected leg towards table (keep other knee at chest)
and ask pt to relax to allow for full extension
 Positive test is that the lower extremity on the involved side will
be unable to fully extend at the hip (ie: thigh/popliteal region will
not lie flat on the table) and signals iliopsoas tension, shortening
or contracture
 Iliopsoas hypertonicity is a common finding in acute and chronic
lower back pain.

Question 15

Gaenslen Test

Answer 15

• With patient supine, flex one hip and knee to chest while
simultaneously extending opposite hip (off side of table)
• Alternative: Lateral recumbent, flex lower hip and hold,
physician then extends top hip
• Maneuver stresses both Sacroiliac Joints
• Posterior pelvic pain indicates a positive test for SIJ dysfunction or
pathology

Question 16

valsalva (sciatica/lumbar considerations)

Answer 16

 Evidence of nerve root irritation typically manifests as sciatica, a
sharp or burning pain radiating down the posterior or lateral
aspect of the leg, usually to the foot or ankle. Pain radiating
below the knee is more likely to represent true radiculopathy
than proximal leg pain. Sciatic nerve pain is often associated with
numbness or tingling.
 Sciatica due to disc herniation usually increases with coughing,
sneezing, or performance of Valsalva maneuver.

Question 17

Kernig’s Sign

Answer 17

 Mechanism of test is similar to Straight Leg Raising
 Place patient supine and flex hip and knee to 90°
 Attempt to passively extend the leg at the knee
 Positive is increased resistance to extension and pain behind knee
(also back pain radiating to posterior thigh considered by some
sources) due to meningeal/dural irritation
 Kernig’s sign is paired with nuchal rigidity testing and Brudzinski’s
sign classically for a patient with meningeal signs
o Frequency of Brudzinski’s and Kernig’s sign in patients
with meningitis has a reported range of 5‐60%
o Sensitivity is low (~5%) and Specificity data is limited

Question 18

Stork Test

Answer 18

Single leg weight‐bearing hyperextension test
 Stand normally, flex hip and knee of one leg
 Stabilize pts iliac crests, if needed, and have them lean back
extending the lower back
 Positive test: pain in lower back as it stresses the posterior
elements of the spine on the ipsilateral side
 Indicates: Possible pars defect/stress fracture
o Could be bilateral fracture  inc. risk for
Spondylolisthesis

Question 19

Cauda Equina Syndrome

Answer 19

Condition of spinal nerve root compression usually by massive
disc protrusion, fracture/trauma or tumor that results in
bowel/bladder dysfunction
o No one single test for Cauda Equina syndrome but clinical
features that require investigation include
 Pain (usually first symptom, present in 83‐95% of
pts at time of diagnosis)
 Can precede neurologic symptoms by
weeks in cases not secondary to
immediate trauma
 Bowel/bladder dysfunction (overflow
incontinence)
 Sensory loss of perineum (“Saddle Anesthesia”) &
decreased anal sphincter tone
 Bilateral sciatica and leg weakness

Question 20

spina bifida occulata

Answer 20

Congenital and asymptomatic
o Most common at L5‐S1
o May find coarse patch of hair or birthmark or dimple
o Small split in vertebra, NO spinal cord protrusion
o Usually incidental finding on radiograph

Question 21

spina bifida menigocele

Answer 21

Meninges forced out between vertebra

o Surgically repaired, usually no neurological damage

Question 22

spina bifida melomenigocele

Answer 22

Most common type
o Unfused portion of spinal cord protrudes through opening
o Very severe (permanent) neurologic complications