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British Medical Books Health Issues Computerized Tomography

Examination of the Lumbar Spine

History

  • age & occupation
  • onset of the pain:
    • onset slow and insidious, rapid, or sudden
    • constant or remissions
    • related to any particular posture
  • history of an injury(sudden twist, strain)
  • any relevant previous Hx
    • any previous trouble with the spine?
    • any associated illness or malaise?

Symptoms

Pain

  • sharp & localized (knife-like) or chronic & diffuse
  • often extending into the upper part of buttock

Sciatica

  • pain radiating from the buttock into the thigh & calf –> type of referred pain
  • in the distribution of the sciatic nerve
  • rarely due to sciatic nerve pathology –> from a lumbar or sacral nerve root
  • intense, aggravated by coughing or straining
  • symptoms of root pressure(numbness or paraesthesia)

Stiffness

  • sudden in onset (after a disc prolapse)
  • continuous and worse in the mornings(arthritis or AS)

Deformity

  • usually noticed by others
  • shoulder asymmetry or clothes not fitting

Numbness or paraesthesia

  • anywhere in the lower limb
  • mapped over one of the dermatomes
  • aggravated by standing or walking & relieved by sitting down –> spinal stenosis

Weakness

  • disturbance of gait or balance
  • giving way of ankles

Urinary or faecal incontinence,impotence

  • pressure on the cauda equina –> emergency

Other symptoms

  • weight loss
  • malaise, fever, night sweat, cough
  • urethral discharge, diarrhoea and sore eyes –> Reiter’s disease

Physical examination

Patient standing and sitting

Inspection

Skin

  • scars, pigmentation (cafe-au-lait), abnormal hair or skin creases, fat pad

Muscle wasting

  • leg, back or abdominal

Shape and posture

  • asymmetry of the chest, trunk or pelvis(shoulders & pelvis in level)
  • when the patient bends forward

from behind:

  • lateral deviation –> scoliosis
    • protective –> disc prolapse
    • postural or mobile (disappears on bending forward)or structural (remains on bending - rib hump)

from the side:

  • thoracic spine –> kyphosis
    • if regular –> senile kyphosis, Sheuermann’s dx or ankylosing spondylitis
    • if sharply angulated –> kyphos or gibbus(#,TB or congenital anomaly)
  • lumbar spine –> flat(muscle spasm –> disc,infection,#)
  • –> excessively lordosed (normal in women,spondylolisthesis or secondary to increased thoracic curve or FFD of the hips)
  • stands with one knee bent –> nerve root tension on that side

Palpation

  • look for localized tenderness

Spinous processes

  • L4-5 junction in level with the iliac crest
  • small processes or absence –> spina bifida
  • palpable “step-off” –> spondylolisthesis
    • most often L5 on S1, or L4 on L5
  • tender coccyx (coccygodynia)

Supra - & Interspinous ligaments

  • tenderness or a ‘step’(rupture, dislocation)

Paraspinal muscles

  • three layers
    • superficial (sacrospinalis system: spinalis,longissimus & iliocostalis) palpable
  • note tenderness, spasm, rigidity or atrophy

Iliac crest

  • gluteal muscles originate
  • neuroma of the cluneal nerves cause tenderness

Posterior superior iliac spine

  • avulsion of sacrotuberous ligaments in SI inj.

Sciatic nerve

  • tenderness at the midpoint between the ischial tuberosity & GT

Percussion

  • from the neck to the sacrum
  • marked pain in TB & other infections

Movements

Flexion

  • touch his toes
    • eliminate hip flexion
    • smoothness of movement
    • measure the spinal excursion
    • distance of fingers from the ground
    • increase of distance between the spinous processes T1-L1 & L1-S1
    • decreased if painful, paraspinal spasm
    • back to the upright position by pushing on knees –> lumbar instability

Extension

  • lean backwards, while steadying the pelvis & pulling back on the shoulder
  • ‘wall test’ for minor flexion deformity (heels buttocks,shoulders and occiput should all make contact)
  • pain common in slipped disc

Lateral flexion

  • bend sideways, sliding hand down the leg
  • the two sides compared

Rotation

  • twist the trunk each way
  • stabilise pelvis holding the iliac crest
  • 40°, almost entirely thoracic

Rib excursion

  • measure chest circumference in ex-& inspiration

Signs with the patient lying

Palpation

Abdominal examination

  • sacral promontory
  • pulsatile haematoma, mass –> AAA, tumour
  • abdominal muscles
    • if weak –> abN lumbar lordosis
    • segmental innervation
  • inguinal area
    • femoral pulse
    • psoas abscess
    • hernia
    • hip pathology

Rectal & vaginal examination

  • anal tone
  • sensation
  • coccygeal pain

Sacro-iliac joint

  • pelvic compression
  • flex hip & knee, then forcibly adduct the hip
  • pain in ankylosing spondylitis & infections

Movement

Hip screening

  • OA may mimic back pain
  • FFD

Straight leg raising test

  • start at painfree side
  • normal ROM 70-120°
  • watch face for pain
  • back pain –> central disc prolapse stretching the spinal cord
  • leg pain –> lateral protrusion stretching sciatic nerve roots
  • eliminate hamstring tightness
  • dorsiflexion of foot, pressure with the thumb at the popliteal fossa or neck flexion increases pain

Cross leg straight leg raising test

  • if well-leg raising produces sciatic pain

Reverse Lasegue test (femoral N stretch)

  • pt. prone, flex knee and extend hip –> femoral nerve stretched (L2-3)

Kernig test

  • forcibly flex neck –> stretches spinal cord

Neurologic examination

Myotomes  
Hip flexion L2-L3 (iliopsoas)
Hip extension L4-L5 (Gmax., hamstrings)
Knee extension L3-L4 (quadriceps)
Knee flexion L5-S1 (hamstrings)
Ankle dorsiflexion L4-L5 (tib.ant.,hall.longus)
Ankle plantarflexion S1-S2 (calf muscles)
Foot inversion L4 (tibialis ant.)
Foot eversion L5-S1 (peronei)
Power grading chart (0-5)
  • zero-trace-poor-fair-good-normal

Dermatomes

  • fine touch & joint position sense –> dorsal columns of the spinal cord
  • pain and temperature sensation –> lateral and ventral column
Dermatones

Reflexes

  • in arms, legs and sphincters

Deep tendon reflexes = LMN reflexes: mediated by anterior horn

  • increased in UMN lesion, lost in LMN lesion
  • T12,L1/2/3 ––> no reflex
  • L4 ––> patella jerk
  • L5 ––> tib.post.reflex
  • S1 ––> ankle jerk

Superficial reflexes = UMN reflexes: mediated by cerebral cortex

  • lost in UMN lesion
  • abdominal : T 7 – T 12
  • cremaster : T 12
  • superficial anal : S2–3–4

Pathological reflexes - also superficial

  • if presents –> UMN lesion
  • Babinski (positive: great toe extension,others plantar flex)
  • Oppenheim (fingernail over the crest of the tibia - same reaction as B.)

Rectal examination

Bulbocavernosus reflex

  • response of the anal sphincter to pressure exerted on the glans penis
  • connections in the conus medullaris at L1
  • not normally present
  • if present –> indication of the passing of the spinal shock in a patient with complete lesion
  • to test it the reflex arc must be intact
    • lesion at the level of the conus medullaris damaging reflex arc would give negative test

Priapism

  • spontaneous erection –> poor prognostic sign