Lumbar spine tests (w/MRS)

Question 1

L1, L2 Nerve root motor test

Answer 1

Muscle: iliopsoas
Action: raise bent knee
Peripheral nerve: Ventral rami and Femoral n.

Question 2

L3 Nerve root motor test

Answer 2

Muscle: quadriceps
Action: leg extension
Peripheral nerve: Femoral nerve

Question 3

L4 Nerve root motor test

Answer 3

Muscle: Tibialis anterior
Action: ankle dorsiflexion
Peripheral nerve:

Question 4

L5 Nerve root motor test

Answer 4

Muscle: tibialis anterior
Action: ankle dorsiflexion

Muscle: Peroneus longus and brevis
Action: ankle eversion

Peripheral nerve: Deep peroneal nerve

Question 5

S1 Nerve root motor test

Answer 5

Muscle: Gastrocnemius/Soleus
Action: ankle plantar flexion

Muscle: Flexor hallucis longus
Action: big toe flexion

Peripheral nerve: tibial nerve

Question 6

L4 nerve root reflex test

Answer 6

Muscle: patella
Response: brisk contraction of quadriceps m. and extension of leg at knee

Question 7

L5 nerve root reflex test

Answer 7

Muscle: hamstrings
Response: brisk contraction of the medial hamstring m. (semitendinosus)

Question 8

S1 nerve root reflex test

Answer 8

Muscle: achilles
Response: brisk contraction of gastrocsoleus and plantar flexion of foot

Question 9

L3 nerve root sensory test

Answer 9

Central quad, high

Question 10

L4 nerve root sensory test

Answer 10

Central quad, low

Question 11

L5 nerve root sensory test

Answer 11

outside of the calf

Question 12

S1 nerve root sensory test

Answer 12

lateral calf

Question 13

Diagnostic Cluster for Lumbar Stenosis

Answer 13

• Relief during immediate sitting is strongly suggestive of spinal stenosis
• The most diagnostic combination included a cluster of:

1. bilateral symptoms;
2. leg pain more than back pain;
3. pain during walking/standing;
4. pain relief upon sitting;
5. age >48 years.
6. Meeting any one of five positive findings demonstrated a high sensitivity of 0.96 (95% CI = 0.94-0.97) and a low negative likelihood ratio (LR-) of 0.19 (95% CI = 0.12-0.29).
7. Meeting four of five findings yielded a LR+ of 4.6 (95% CI = 2.4-8.9) and a post-test probability of 76%.

Question 14

Diagnostic Cluster for Cauda Equina Syndrome

Answer 14

• Rapid symptoms within 24 hours 89% sensitivity
• History of back pain 94% sensitivity
• Urinary retention 90% sensitivity
• Loss of sphincter tone 80% sensitivity
• Sacral sensation loss 85% sensitivity
• Lower extremity weakness or gait loss 84%sensitivity

Question 15

Diagnostic Cluster for Lumbar Radiculopathy

Answer 15

• Dermatomal pattern (OR = 4.1)
• Pain on cough, sneezing, straining (OR = 3.2)
• More pain Sitting (OR=1.9)
• Subjective muscle weakness (OR = 2.2)
• Subjective Sensory loss (OR = 2.1)
• Paresis/Motor Loss (OR = 3.7)
• +SLR (OR = 3.9)
• Unilat Ankle reflex (OR = 3.9)

Question 16

Bechterew’s test

Answer 16

Positioning: Patient seated

Instruction: Keep your back straight and extend your leg

Technique: Observe. Don’t let pt lean back to reduce pain

Interpretation: Symptoms down posterior thigh
past knee indicates possible
L4, L5 or S1 radiculopathy due to:
 herniated disc
 stenosis
 osteophytes
 tumors … bone, meninges, soft
tissue
 local infection or fracture

Question 17

Slump test

Answer 17

Positioning: Pt seated upright, arms behind back; stand at the side

Instruction: Let me know if you feel anything at any point

Technique:

1. patient “slumps” with cervical extension (stretching sciatic nerve)
2. cervical spine is fully flexed and released
3. one knee maximally extended … cervical spine is fully flexed and released
4. dorsiflex ankle … cervical spine is fully flexed and released

Interpretation: Stretching the sciatic nerve to recreate pain. Lots of hamstring tightness, different quality of pain (burning, aching vs tingling, numbness of radiculopathy)

Question 18

Kemp’s test

Answer 18

Positioning: Pt seated, stand behind. One hand on shoulder for support. other hand on the lamina (if testing the right side, left hand will be just off the right of the SPs)

Instruction: Let me know if there’s pain along the way.

Technique: Trunk extension, ipsilateral
lateral flexion, and slight
ipsilateral rotation around
contact hand

Interpretation: Positive is low back pain with or without pain radiating down leg
• Nerve root compression if pain radiates
• Local low back pain without radiating pain …muscle strain / ligamentous strain / facet irritation / capsular inflammation

Question 19

Straight leg raise

Answer 19

Positioning: Pt supine. Stand to the side One hand above knee, other pressing up on heel.

Instruction: let me know when there’s pain

Technique: Passively elevate straight leg. Note angle of onset of pain

Interpretation:
o “Hard” positive – sharp, burning, electrical pain past knee with hip flexed 35°-70°
• Sciatic nerve irritation / L4-S1 nerve roots radiculitis from herniation, tumor, spinal canal stenosis, osteophytes
o “Soft” or “equivocal” positive – pain radiating into lower extremity but not past knee
• meaningful – other evidence of nerve root or sciatic n. is inflamed / compressed
• insignificant – no other evidence supports a radicular syndrome
Every soft positive: stop, drop leg a bit to relieve the pain. Then run sicard’s or bragard’s.
o Negative test – no pain, pain in back, pain to buttocks
• suggests nerve root is not involved / most likely sacroiliac or lumbar
o Focal point of pain in the leg or pelvis
• “alarm sign” suggesting a tumor in location of pain

Question 20

Sicard’s test

Answer 20

Positioning: Immediately after positive straight leg raise

Instruction:

Technique: lower straight leg 5°-10° or to height just below the level causing symptoms then dorsiflex (extend) the great toe

Interpretation: Duplication or increase in pain suggests sciatic radiculopathy or nerve root compression

Question 21

Bragard’s test

Answer 21

Positioning: Immediately after positive straight leg raise

Instruction:

Technique: lower straight leg 5°-10° or to height just below the level causing symptoms then dorsiflex (extend) the foot

Interpretation: Duplication or increase in pain suggests sciatic radiculopathy from …
disc herniation
encroachment
space occupying lesion

Question 22

Well leg raise

Answer 22

Positioning: Pt supine, stand to the unaffected side

Instruction: Let me know where there’s pain, don’t try to help.

Technique: passively elevate the non-symptomatic straight leg from the table

Interpretation: Positive is increased symptoms in the symptomatic leg
• nerve root irritation : disc lesion – disc herniation, encroachment by osteophytes next step would be imaging