Evaluation of the Lumbar Spine. Outline of Presentation Overview Anatomy Steps in the evaluation of the LS.

Evaluation of the Lumbar Spine

Outline of Presentation

• Overview• Anatomy• Steps in the evaluation of the LS

Overview

• At some time in their lives, 80% of the general population will experience some type of low back pain (LBP) - it is second only to the common cold as a reason for physician visits, and the most expensive source of compensated work related injury in modern industrialized countries

• Despite the frequency of LBP and the many studies examining LBP, LBP is a difficult problem to investigate and several key issues concerning its occurrence, natural history and prognosis remain unanswered

Overview

• 90% LBP resolves without medical attention in 6-12 weeks

• 50% LBP resolves within 1 year • Even 75% sciatica resolves within 6mo• Recurrence may be 80% within 1 year(Frymoyer JW. Back pain and sciatica. N Engl J Med 1988;318:291-300) (Vanharanta H.Etiology, epidemiology and natural history of lumbar disc disease.

Spine State Art Rev 1989;3:1-12)

Overview

• The lumbar spine supports the upper body and transmits the weight of the body to the pelvis and lower limb

• Unless there is a definite history of trauma, there is a difficulty to determine whether the symptoms originate in the hip ,LS or SI joint

Anatomy

• The lumbar spine consists of 5 lumbar vertebrae• Between each of the lumbar vertebrae is the

intervertebral disc (IVD)• The articulations between two consecutive lumbar

vertebrae form three joints– One joint is formed between the two vertebral bodies and

the intervertebral disc (IVD)– The other two joints are formed by the articulation of the

superior articular process of one vertebra and the inferior articular processes of the vertebra above.

Lumbosacral spine

• 5 weight bearing Lumbar vertebrae

• Atypical: Sacralized L5 Complete -1%

Incomplete -6%• Atypical: Lumbarized S1

=> L6 about 4%

Anatomy

• Vertebra– In general, the lumbar vertebrae increase in size

from L 1 to L 5 in order to accommodate progressively increasing loads

Anatomy

• Ligaments– Anterior longitudinal ligament (ALL)• Extends from the sacrum along the anterior aspect of

the entire spinal column, becoming thinner as it ascends

– Posterior longitudinal ligament (PLL)• Found throughout the spinal column, where it covers

the posterior aspect of the centrum and IVD

Anatomy

• Ligaments– Ligamentum flavum (LF)• Connects two consecutive laminae

– Interspinous ligament • Connects two consecutive spinal processes

– Supraspinous Ligament• Connects the tips of two adjacent spinous processes

Anatomy

• Muscles– Quadratus Lumborum• The importance of this muscle from a rehabilitation

viewpoint is its contribution as a lumbar spine stabilizer– Lumbar multifidus (LM)• The lumbar multifidus is an important muscle for

lumbar segmental stability through its ability to provide segmental stiffness and control motion

Anatomy

• Muscles– Erector spinae• The erector spinae is a composite muscle consisting of

the iliocostalis lumborum and the thoracic longissimus. Both of these muscles are subdivided into the lumbar and thoracic longissimii and iliocostallii

Anatomy

• Muscles– Thoracolumbar fascia (TLF)• Assists the in transmission of extension forces during

lifting activities • Stabilizes the spine against anterior shear and flexion

moments

Examination

• The physical examination of the lumbar spine must include a thorough assessment of the neuromuscular, vascular and orthopedic systems of the hip, lower extremities, low back and pelvic regions

Examination

• History– The clinician should establish the chief complaint

of the patient, in addition to the location, behavior, irritability, and severity of the symptoms

– Although dysfunctions of the lumbar spine are very difficult to diagnose, the history can provide some very important clues

Evaluation of low back pain

HISTORY•Location of pain•Mechanism of onset•Degree of irritability•Radiation•Aggravating and relieving factors•Associated features-sensory, motor

Examination

• Systems Review– It must always be remembered that pain can be

referred to the lumbar spine area from pathological conditions in other regions

Examination

• Observation– Observation involves an analysis of the entire

patient as to how they move, and respond in addition to the positions they adopt

– Although spinal alignment provides some valuable information, a positive correlation has not been made between abnormal alignment and pain

Inspection

• Normal Posture– Shoulders and pelvis level– Bony and soft tissue symmetry– 1 = Cervical lordosis– 2 = Thoracic kyphosis– 3 = Lumbar lordosis – 4 = Sacral kyphosis

Inspection

• Abnormal Posture (Standing)– Listing to one side: sciatic

scoliosis (herniated disc)– Lumbar lordosis absent:

paravertebral muscle spasm– Extremely sharp kyphosis:

Gibbus Deformitiy– Exaggerated lumbar lordosis:

weak abd wall muscles

Examination

• Palpation– Whenever it is performed, palpation of the lumbar

spine area should be performed in a systematic manner, and should be performed in conjunction with palpation of the hip and pelvic area

Bony Palpation: Posterior

• Iliac crest L4-5, count spinous processes above L4-5 reference point

• Posterior superior iliac spines (PSIS)• Spinous processes• Tranverse processes• Sacroiliac joint• Paraspinal muscles• Gluteal muscles

Bony Palpation Posterior: Abnormal

• Spondylolisthesis– “Step off”– Forward slippage of process onto another, L5 on S1 or L4 on L5

• Spondolysis (pars interarticularis defect), seen in gymnasts and fast bowers, tennis, high jump, throwing athletes

• Coccydynia– Tailbone pain, usually result of direct blow or fall

• Spina bifida– Gaps between or missing lumbar or sacral spinous processes

Examination

• Active range of motion– Normal active motion, which demonstrates

considerable variability between individuals, involves fully functional contractile and inert tissues, and optimal neurological function

– It is the quality of motion and the symptoms provoked, rather than the quantity of motion that is more important

Flexion

• 40 to 60 degrees

Extension

• 20 to 35 degrees

Lateral Bending

• 15 to 20 degrees

Rotation

• 3 to 18 degrees

Passive Range of movement

• Difficult to carryout PROM of the LS• Over pressure may be applied at the end of

AROM

Resisted Muscle testing

• Performed in a neutral position with the patient seated to stabilise the hip

• Instruction “do not let me move you”

• Flexion ,extension, side flexion, rotation

Examination

• Key muscle tests– The key muscle tests examine the integrity of the

neuromuscular junction and the contractile and inert components of the various muscles

– With the isometric tests, the contraction should be held for at least five seconds to demonstrate any weakness

– If the clinician suspects weakness, the test is repeated 2-3 times to assess for fatiguability, which could indicate spinal nerve root compression.

Lower limb scan

• Hip joint• Knee joint• Ankle joint• Foot

Special tests

• Straight Leg Raise /Lasegue test- used to assess tight hams or irritation of sciatic nerve

• Slump test- to assess lumbar nerve root compression

• Sacroiliac Joint test/Faber test – assess the SI jt

Special Tests cont’d

• Dynamic abdominal endurance test

• Prone knee bend test- stresses the femoral nerve and L2- L4 nerve root

• Stork test – to detect stress injury in the posterior elements of the lumbar spine

Neurological examination

Myotomes

• L2 – Hip flexion• L3 – knee extension• L4– Dorsiflexion• L5- Extension of great toe• S1- ank plantflexion• S2- knee flexion

Straight Leg RaiseTest (lower plexus)Normal test: angle of

elevation > 70 degrees with only mild discomfort/hamstring tightness

Stretches: L5, S1 nerve roots (w/ little tension on proximal nerves)

Positive test: reproduces pain along distribution of sciatic nerve

Sensitivity: 90% Specificity: 25%

Neural Tension TestsStraight leg Raise Test

Faber (Patrick) Test

• Hip and SI joint test• Patient supine• Hip flexed, abducted,

externally rotated• +inguinal pain: hip• Press on knee and

opposing hip• +back pain: SI joint

ASIA Dermatomes

• L3 medial knee• L4 medial shin• L5 great toe• S1 lateral heel/

lateral foot• S2 posterior knee

References

• Orthopaedic Physical Assessment by David Magee

• Orthopaedic Medicine by Monica Kesson and Elaine Atkins

• Living Surface Anatomy by Philip Harris and Craig Ranson