Download Lumbar Spine

Lumbar Spine
Orthopedic Tests
Lumbar Anatomy
Erector Spinae Group
Quadratus Lumborum
Gluteal Muscles
Spondylolysis
A defect of the vertebral body with NO forward
movement of one vertebra on another.
A defect of the pars interarticularis.
Pars fracture is most common at the L5 level, but can
occur in other lumbar vertebra and in the thoracic
spine as well.
Spondylolisthesis
A defect of the vertebra with forward movement of one
vertebra on another.
The defect of the pars interarticularis allows ofr the
forward migration of one vertebra on another.
Spondylolisthesis Grades
Grade 1
0-25% forward movement
Grade 2
25-50% forward movement
Grade 3
50-75% forward movement
Grade 4
75-100% forward movement
Spinal Percussion Test
Procedure: Patient seated. Bent slightly forward. Tap
the spinous processes and associated musculature with
a reflex hammer.
Positive Test: Local pain – fracture without
neurological compromise. Radicular pain – fracture or
disc defect with neurological compromise. Pain in
paraspinal musculature – muscle strain.
Spinal Percussion Test
Referred Pain Vs. Radicular
Pain
Lower extremity pain may be referred from
lumbopelvic tissues or viscera. It may also be radicular
pain from the nerve roots of the spine.
Referred pain patterns – the spinal pain is more
aggravating than the lower extremity pain. Referred
pain is poorly localized and dull.
Radicular pain patterns – the leg pain is more
aggravating than the spinal pain. Radicular pain is
sharp and well localized.
Lumbar Nerve Root & Sciatic
Nerve Irritation/Compression
Neurogenic radicular lower extremity pain may be
caused by any one of several factors.
Tension, irritation, or compression of a lumbar nerve
root or roots can cause radicular pain.
Lumbar Nerve Root & Sciatic
Nerve Irritation/Compression
Intraspinal canal compressions – disc lesions, spinal
stenosis, degenerative disc disease, hypertrophic
changes, malignancy.
Extraspinal canal compressions – muscle dysfunction,
extradural defects, masses.
Lumbar Nerve Root & Sciatic
Nerve Irritation/Compression
Clinical Signs and Symptoms
Lower back pain
Lower extremity radicular pain
Loss of lower extremity reflexes
Loss of lower extremity muscle strength
Loss of lower extremity sensation
Straight Leg Raising Test
Procedure: Patient supine. Raise the patient’s leg to a
point of pain or 90 °, whichever comes first.
Straight Leg Raising Test
Positive Test: This test stresses the sciatic nerve and
spinal nerve roots L5, S1, and S2.
Pain after 70° of hip flexion – lumbar joint pain.
Pain at 35° to 70° – sciatic nerve roots tense – pain
due to IVD pathology.
Pain between 0° to 35° – extradural sciatic
involvement (spastic piriformis, SI joint lesion).
Dull posterior thigh pain – tight hamstring.
Straight Leg Raising Test
Lasegue’s Test
Procedure: Patient supine. Flex the patient’s hip with
the leg flexed. Keeping the hip flexed, extend the leg.
Positive Test: Positive test for sciatic radiculopathy
occurs when
(a) no pain is elicited when the hip is flexed and the leg
is flexed.
(b) pain is present when the hip is flexed and the leg is
extended.
Lasegue’s Test
Bragard’s Test
Procedure: Patient supine. Raise leg to point of pain.
Lower the leg 5° and dorsiflex the foot.
Positive Test: Pain due to traction of the sciatic nerve.
Pain with dorsiflexion at 0° to 35° – extradural
sciatic nerve irritation.
Pain with dorsiflexion from 35° – 70° – intradural
problem (usually IVD lesion).
Dull posterior thigh pain – tight hamstring.
Bragard’s Test
Bechterew’s Test
Procedure: Patient seated with legs hanging off the
examination table. Patient extend one knee at a time.
If no response, then extend both together.
Positive Test: Extending the leg puts traction on the
sciatic nerve. Positive test – if patient cannot perform
test due to pain or if patient leans back. Indicates disc
protrusion.
1, 2 Bechterew
Bechterew’s Test
Minor’s Sign
Procedure: Instruct the seated patient to stand.
Positive Test: The patient with sciatic radiculopathy
will stand on the healthy side and keep the affected leg
flexed.
Minor’s Sign
Antalgic Lean Sign
Procedure: Observe the patient while standing.
Patients with disc protrusions that place pressure on a
nerve root will lean in a direction that reduces the
mechanical pressure on the disc.
Antalgic Lean (Disc protrusion
lateral to nerve root)
Positive Sign: If the disc protrusion is lateral to the
nerve root, the patient will lean away from the side of
pain.
Leaning away pulls the nerve root medially away from
the disc defect and relieves pain.
Antalgic Lean (Disc protrusion
lateral to nerve root)
Antalgic Lean (Disc protrusion
medial to nerve root)
Positive Sign: If the disc protrusion is medial to the
nerve root, the patient will lean toward the side of
pain.
Leaning towards the side of the lesion pulls the nerve
laterally away from the disc defect, reducing pressure
on the nerve root.
Antalgic Lean (Disc protrusion
medial to nerve root)
Antalgic Lean (Disc protrusion
central to nerve root)
Positive Sign: If the disc protrusion is central to the
nerve root, the patient may assume a flexed posture.
Leaning forward puts the posterior portion of the disc
under traction, which can reduce the surface area of
the disc that comes into contact with the nerve.
Antalgic Lean (Disc protrusion
central to nerve root)
Kemp’s Test
Procedure: Patient seated or standing. Stabilize the
PSIS with one hand. Reach around the patient with
the other hand and passively bend the dorsolumbar
spine obliquely backward.
Positive Test: Pain in the lower back is a positive test
for lumbar spasm or facet capsulitis. Radicular pain
suggests a disc lesion.
Kemp’s Test
Space-Occupying Lesions
Space-occupying lesions can consist of the following:
Disc defect, degenerative change, synovial cyst, fracture,
tumor, or some combination of these factors.
Space-occupying lesions can lead to spinal stenosis.
Narrowing of the tubular structures of the spine.
Naorrowing of the central canal, lateral recess, or
intervertebral foramen.
Space-Occupying Lesions
Clinical Signs and Symptoms
Lower back pain
Lower extremity radicular pain
Lower extremity weakness
Loss of lower extremity reflexes
Loss of lower extremity sensation
Valsalva’s Maneuver
Procedure: Instruct the seated patient to bear down as
if straining at stool. Concentrate the stress at the
lumbar region. Ask if pain is increased and have the
patient point to it.
Positive Test: The test increases intrathecal pressure.
Positive test indicates a space-occupying lesion.
Valsalva’s Maneuver
Dejerine’s Triad
Procedure: Patient seated. Instruct the patient to
cough, sneeze, and bear down as if straining at stool.
Positive Test: Increased local pain suggests a spaceoccupying lesion.
Lumbar Vs. Sacroiliac Joint
Involvement
Lumbar and/or radicular pain in the leg can be caused
by either a lumbar condition or by a sacroiliac joint
condition.
The following tests help to differentiate between the
two sources of pain.
Sacroiliac Joint Syndrome
Clinical Signs and Symptoms:
Lower back pain
Sacroiliac joint pain
Aggravated by sitting
Alleviated by standing or walking
Lower extremity radicular pain
Goldthwaith’s Test
Procedure: Patient supine. Place one hand under the
lumbar spine with each finger under an interspinous
space. With the other hand perform a straight leg
raising test.
Positive Test: Radicular pain before the fanning out of
the lumbar vertebra indicates an extradural lesion such
as a sacroiliac joint lesion. Radicular pain during
lumbar fanning indicates an intradural lesion such as a
space-occupying lesion. Local pain after lumbar
fanning indicates a posterior lumbar joint disorder.
Goldthwaith’s Test
Nachlas Test
Procedure: Patient prone. Approximate the patient’s
heel to the buttock on the same side.
Positive Test: Stretches the femoral nerve (largest
branch of the lumbar plexus). Radicular pain to the
anterior thigh – compression or irritation of the L2 –
L4 nerve roots by an intradural lesion. Pain in the
buttock – SI joint lesion. Pain in the lumbosacral joint
– lumbosacral lesion.
Nachlas Test