Lumbar Spine Exam
Submitted by Dr.Raj on Fri, 2006-03-24 19:19.
How do you peform Inspection of the
lumbar spine?
Anterior examination
·
Patients with low back pain maintain
a rigid posture to avoid bending, twisting and other movements that can
precipitate pain.
·
If there is disc herniation lateral
to the nerve root, patient may list away from the side to draw the nerve root
away from the disc. If the disc herniation is medial to the nerve root, patient
lists towards the side of the lesion.
Side examination
·
Ear lobe should be in line with the
tip of the shoulder and peak of the iliac crest.
·
A gentle lordosis is normal.
Exaggerated lordosis is seen in hip flexor contracture, weak hip extensors,
spondylolisthesis.
Posterior examination
·
Look for redness, skin markings,
hairy patches, café au lait spots, birth marks, fatty masses, skin tags
·
Inspect the shoulder, scapula and
iliac crest for scoliotic curve.
How do you palpate the lumbar spine?
·
Iliac crest - put hands on iliac
crests on both sides at L4,5 level. Compare the 2 sides of iliac crests.
·
Spine - palpate the spine and look
for any step off seen in spondylolisthesis
·
Tender or Trigger point - palpate
paraspinal muscles for any tender point or a trigger point with taut band and
muscle twitch response.
What are the tests to detect
increased intrathecal pressure?
Kernig test
·
Maneuver: Flex hip and knee to 90
degrees and now slowly extend the leg
·
Response: Resistance to extension due
to pain is a positive test
Brudzinski's test
·
Maneuver: Passively flex the neck
·
Response: Flexion of knee is a
positive test and indicates meningitis
Milgram test
·
Maneuver: Raise both legs up and ask
him to hold the position as long as he can
·
Response: If patient cannot hold
for 30 seconds then intrathecal pathology is likely
How do you measure segmental motion
of the Lumbar spine?
Schober Test
·
Maneuver: Mark S1 (venus dimples) and
mark 10 cm above this point while patient is standing erect. Patient is asked
to flex forward and measure the increase in distance.
·
Response: Normal motion of the lumbar
spine should be atleast 4-5 cm
Modified Schober Test
·
Maneuver: Mark S1 (venus dimples)
when patient is erect. Make a mark 10 cm above S1 and 5 cm below the S1.
Patient is asked to bend forward and measure the increase in distance between
the marks above and below.
·
Response: Normal motion of the lumbar
spine should be atleast 4-5 cm.
Describe the tests useful in
diagnosing lumbar disc herniation?
SLR
·
Maneuver: support the foot with one
hand and put the other hand on the top of the knee to prevent it from bending
and lift the leg up. Elevation of the leg is stopped when patient
begins to feel any pain.
·
Response: Record the type and
distribution of pain as well as the angle of elevation that caused it. The test
is positive when the angle is between 30 and 70 degrees and the pain is
reproduced down the posterior thigh behind the knee. If there is
pain limited to the posterior thigh then it is likely hamstring
pain.
Crossed SLR
·
Maneuver: Perform a SLR
·
Response: If the patient complains of
pain in the other leg then it is crossed SLR positive
Braggard's sign
·
Maneuver: Perform a SLR to the point
of pain provocation. Now drop the leg slightly to a non painful range and
dorsiflex the foot
·
Response: If pain reproduced it is
due to sciatica or disc herniation
Bowstring
·
Maneuver: SLR is done and when
positive, flex the leg and apply pressure to the Tibial nerve in the popliteal
fossa.
·
Response: If pain is reproduced in
the distribution of patient's complaints then it is positive for sciatica or
nerve root irriatation.
Slump Test
·
Maneuver: Patient sits in the chair
with arms behind the back. Now passively extend the knee and ask if the patient
has any radiating pain. Now ask patient to slump forward to produce full trunk
flexion and tuck chin in. Pressure can be added to the head to increase neck
flexion.
·
Response: Reproduction of pain in the
distribution of patient's complaints is positive for sciatica or nerve root
irritation.
Femoral nerve stretch test
·
Maneuver: Patient lies prone.
Examiner places palm of the hand in the popliteal fossa and flexes the knee.
·
Response: Excruciating pain along the
anterior aspect of the thigh. The test should reproduce the pain in the
distribution of patient's complaints.
Crossed femoral nerve stretch test
·
Maneuver: Perform a Femoral nerve
stress test
·
Response: Patient should experience
pain in the distribution of patient's complaints in the contralateral leg
What are simple tests to assess nerve
roots?
Heel walking test
·
Maneuver: Ask patient to walk on heel
·
Response: Inability to walk on heel
is indicative of L5 weakness
Toe walking test
·
Maneuver: Ask patient to walk on toes
·
Response: Inability to walk on toes
is indicative of S1 weakness
What are the tests to detect
myofascial pain?
Skin pinch test
·
Maneuver: pinch the skin and roll
between thumb and index finger
·
Response: any tenderness is
indicative of myofascial pain
Percussion test
·
Maneuver: percuss the paraspinal
muscles
·
Response: Pain is indicative of
myofascial origin
What are the tests for malingering?
Hoover test
·
Maneuver: Cup hands under both
feet and ask patent to lift one leg at a time
·
Response: If the pt is trying he
will press the other leg down. If pt is not trying there won’t be any pressure
under the other leg.
Waddell signs (mnemonic - ROADS)
·
Regionalization -
weakness or sensory loss without a pattern. Patient may complain of numbness
involving the entire extremity, entrire leg, leg below the knee, quarter or
half of the body. In patients with normal strength, the sudden letting go
of a muscle may be described as "cogwheeling". In patients with
physical weakness, the muscle is smoothly overpowered with no jerking, and the
response throughout a resisted range-of-motion maneuver remains smooth and
constant. Patient with non organic pain does not have this smooth motion.
·
Overreaction -
exaggerated response to non painful stimulus. Patient may exaggerate response
to non painful stimulus in the form of facial expressions, tremor,
verbalization, muscle tension or fainting. Patient may be hypersensitive
to light touch at one point during examination but later give no response to
touching of the same area.
·
Non Anatomic pain -
Tenderness that crosses multiple somatic boundaries without any anatomic
distribution. Patient also shows dramatic reproduction of pain with light touch
of the back or skin rolling.
·
Distraction -
Patient may complain of pain or limitation in range in a supine straight leg
raising test but there is lack of pain when examiner extends the knee with the
patient seated, and looking at the foot for pulses, Babinski or reflex
testing.
·
Simulation - These
give the patient the impression that a particular test is being carried out
when in fact it is not. Pressing down on the top of the head of a standing
patien should not produce low back pain.Low back pain on sham rotation of the
spine or axial loading. In a standing position, when the shoulders and pelvis
are rotated in unison, the structures in the back are not stressed and should
not cause any pain.
