Lumbar Spine Exam

Question 1

Palpation/Inspection

Answer 1

Palpation spinous process

• tenderness
• vertebral step offs

Palpate sacroiliac joint
- tenderness common in sacroiliitis

Inspect/palpate paravertebral muscles

• tenderness
• spasm

Inspect/evaluate skin

Question 2

ROM

Answer 2

Flexion: 40 - 90 degrees
Extension: 20 - 45 degrees
Side Bending: 15 - 30 degrees
Rotation: 3 - 18 degrees

Question 3

Muscle Strength

Answer 3

L1

• femoral n.
• iliopsoas m. (L1-L3)
• hip flexion

L2-L4

• femoral n.
• obturator n.
• quadriceps (knee extension) (L4)
• iliopsoas (hip flexion) (L4-L5)
• hip adductors (L2-L3)
• L4 also has some hip abduction

L5

• perineal n.
• tibial n.
• superior gluteal n.
• gluteus medius (hip abduction) (L4, L5, S1)
• tibialis anterior (ankle dorsiflexion) (L4-L5)
• peroneus muscles (ankle eversion)
• tibialis posterior (ankle inversion) (L5)
• walk on heels

S1

• inferior gluteal n.
• sciatic n. (L4 - S3)
• tibial n.
• gastrocnemius (ankle plantarflexion) (S1)
• gluteus Maximus (hip extension) (S1)
• hamstrings (knee flexion) (L5-S1)
• walk on toes

L5 = most common ridiculous they affecting the lumbar spine

True muscle weakness is the most reliable indication of persistent nerve compression with loss of nerve conduction

Question 4

DTRs

Answer 4

Hyperactive reflexes - upper motor neuron lesion
- look for associated UMN findings of weakness, spasticity, + babinski sign

Hypoactive reflexes - lower motor neurons, diseases of spinal nerve roots
- look for associated LMN findings of weakness, atrophy, fasciculations

Patellar = L4

Achilles = S1

Question 5

Straight Leg Raise

Answer 5

Lumbosacral radiculopathy and/or sciatic neuropathy
Compression of spinal nerve roots passing through vertebral foramen

Positive sign between 30 - 60 degrees

Pain above 70 degrees - increased likelihood of mechanical low back pain due to muscle strain or joint disease

High sensitivity, low specificity

Question 6

Contralateral (Crossed) Straight Leg Raise

Answer 6

Lumbosacral radiculopathy and/or sciatic neuropathy

Positive test when radicular pain is produced in the affected leg with lifting the unaffected leg

Poor sensitivity, high specificity for disc herniation

Question 7

Hoover’s Sign

Answer 7

Malingering or functional weakness “conversion disorder”

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 the hip

Question 8

Thomas Test

Answer 8

Psoas tension

Positive test = lower extremity on the involved side will be unable to fully extend at the hip
Signals iliopsoas tension, shortening, or contracture

Iliopsoas hypertonicity is a common finding in acute and chronic lower back pain

Question 9

Gaenslen Test

Answer 9

SI Joint Pain

Stresses both sacroiliac joints

Posterior pelvic pain = positive test for SIJ dysfunction or pathology

Question 10

Valsalva

Answer 10

Sciatica/lumbar considerations

Sciatica due to disc herniation

Increases with coughing, sneezing, or performance of Valsalva maneuver

Evidence of nerve root irritation - sharp, burning pain radiating down posterior or lateral aspect of leg usually to foot or ankle
Sciatica - often associated with numbness or tingling

Question 11

Kernig’s Sign

Answer 11

Meningeal irritation

Positive = increased resistance to extension and pain behind knee due to meningeal/dural irritation

Paired with nuchal rigidity testing and Brudzinski’s sign

Question 12

Stork Test

Answer 12

Positive = pain in lower back as it stresses the posterior elements of the spine on the Ipsilateral side

Indicates - possible pars defect/stress fracture

Question 13

Cauda Equina Syndrome

Answer 13

Spinal nerve compression - massive disc protrusion, fracture/trauma, tumor

• pain (83-95% of patients)
• bowel/bladder dysfunction (overflow incontinence)
• sensory loss of perineum (“saddle anesthesia”) & decreased anal sphincter tone
• bilateral sciatica and leg weakness

Emergency: requires emergent management and surgical decompression within 48 hrs or permanent neurologic damage can remain

Question 14

Spina Bifida

Answer 14

Failure of lamina fusion in vertebra

Question 15

Spina Bifida Occulta

Answer 15

Congenital
Asymptomatic
most common at L5-S1
May find coarse patch of hair or birthmark or dimple
Small split in vertebra, NO spinal cord protrusion
Usually incidental finding on radiograph

Question 16

Meningocele

Answer 16

Meninges forced out between vertebra
Surgically repaired
Usually no neurological damage

Question 17

Myelomeningocele

Answer 17

Most common type
Infused position of spinal cord protrudes through opening
Very severe (permanent) neurologic complications

Question 18

Ferguson’s Angle

Answer 18

30-40 degrees = normal lumbosacral angle

Helps determine any musculoskeletal problems or postural variations

Question 19

Spondylolysis

Answer 19

Fracture of pars interarticularis

Question 20

Spondylolisthesis

Answer 20

Anterior slippage of one vertebra or another after a pars interarticularis fracture (spondylolysis)

Grading:

• Grade 1: 25% slippage
• Grade 2: 50 % slippage
• Grade 3: 75% slippage
• Grade 4: 100% slippage

Question 21

Osteoarthritis (Spondylosis)

Answer 21

Narrowed intervertebral disc

Bone spur

Question 22

Observation

Answer 22

Slumped over:

• depression
• muscle spasm
• reactive effort

Erect stance
- protecting herniated disc or effects of spinal stenosis

Asymmetry

• iliac crest heights, greater trochanter heights, asymmetric sacral sulcus depths
• scoliosis

Lumbar lordosis

Gait changes

• listing of trunk to one side
• antalgic or limping gait
• foot drop, hiking up, rotation of lower extremity
• shuffling or finest rated gait