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

Dermatomes

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

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