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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 Neural Tension Tests Straight leg Raise Test 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% 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