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Anatomy and Physical Examination of the Lower Back

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1 Anatomy and Physical Examination of the Lower Back
Sports Medicine Fellowship Uniformed Services University of the Health Sciences

2 Objectives Review the functional anatomy of Lumbar spine
Review Physical Examination of LS spine Correlate clinico-pathologic dx with pertinent physical findings


4 Epidemiology of back pain
The most common musculoskeletal disorder in industrialized societies Second only to common cold as cause of lost work time Estimated that ~ 80% of population will experience at least one disabling episode of back pain at some time during their lifetime The most common cause of disability in persons under the age of 45

5 Epidemiology of back pain (cont.)
When compensation from lost work, long-term disability, and medical and legal expenses are considered, is the most costly of all medical dx’s

Onset Palliative/Provocative factors Quality Radiation Severity/Setting in which it occurs Timing of pain during day Understanding - how it affects the patient Onset Palliative/Provocative factore Quality Radiation Severity/Setting in which it occurs Timing of pain during day Understanding - how it affects the patient

7 “Red Flags” in back pain
Hx of cancer Unrelenting nocturnal pain Weight loss Fever, chills, night sweats Age < 15 or > 50 Neurologic deficits Decreased motor and/or sensory innervation Urinary and/or fecal incontinence

8 Anatomy Vertebra Body, anteriorly Functions to support weight
Vertebral arch, posteriorly Formed by two pedicles and two laminae Functions to protect neural structures



11 Ligaments Anterior longitudinal ligament
Posterior longitudinal ligament Interspinous ligament Supraspinous ligament Ligamentum flavum



14 Physical Examination Inspection Palpation Bony Soft Tissue
Range of Motion Neurologic Examination Special Tests

15 Inspection Observe for areas of erythema Infection
Long-term use of heating element Unusual skin markings Café-au-lait spots Neurofibromatosis Hairy patches (Faun’s beard) Lipomata Spina bifida


17 Inspection (cont.) Posture Shoulders and pelvis should be level
Bony and soft-tissue structures should appear symmetrical Normal lumbar lordosis Exaggerated lumbar lordosis is common characteristic of weakened abdominal wall



20 Bone Palpation Palpate L4/L5 junction (level of iliac crests)
Palpate spinous processes superiorly and inferiorly S2 spinous process at level of posterior superior iliac spine Absence of any sacral and/or lumbar processes suggests spina bifida Visible or palpable step-off indicative of spondylolisthesis






26 Soft Tissue Palpation 4 clinical zones Midline raphe
Paraspinal muscles Gluteal muscles Sciatic area Anterior abdominal wall and inguinal area






32 Range of Motion Flexion Extension Lateral Bending Rotation




36 Flexion - 80º Extension - 35º Side bending - 40º each side Twisting º

37 Neurologic Examinaion
Includes an exam of entire lower extremity, as lumbar spine pathology is frequently manifested in extremity as altered reflexes, sensation and muscle strength Describes the clinical relationship between various muscles, reflexes, and sensory areas in the lower extremity and their particular cord levels

38 Neurologic Examination (T12, L1, L2, L3 level)
Motor Iliopsoas - main flexor of hip With pt in sitting position, raise thigh against resistance Reflexes - none Sensory Anterior thigh

39 Neurologic Examination (L2, L3, L4 level)
Motor Quadriceps - L2, L3, L4, Femoral Nerve Hip adductor group - L2, L3, L4, Obturator N. Reflexes Patellar - supplied by L2, L3, and L4, although essentially an L4 reflex and is tested as such

40 L2, L3, L4 testing

41 Neurologic Examination (L4 level)
Motor Tibialis Anterior Resisted inversion of ankle Reflexes Patellar Reflex (L2, L3, L4) Sensory Medial side of leg


43 Neurologic Examination (L5 level)
Motor Extensor Hallicus Longus Resisted dorsiflexion of great toe Reflexes - none Sensory Dorsum of foot in midline


45 Neurologic Examination (S1 level)
Motor Peroneus Longus and Brevis Resisted eversion of foot Reflexes Achilles Sensory Lateral side of foot


47 Special Tests Tests to stretch spinal cord or sciatic nerve
Tests to increase intrathecal pressure Tests to stress the sacroiliac joint

48 Tests to Stretch the Spinal Cord or Sciatic Nerve
Straight Leg Raise Cross Leg SLR Kernig Test



51 Test to increase intrathecal pressure
Valsalva Maneuver Reproduction of pain suggestive of lesion pressing on thecal sac


53 Tests to stress the Sacroiliac Joint
Pelvic Rock Test FABER Test


55 Flexion A- Bduction External Rotation

56 Non-organic Physical Signs (“Waddell’s signs”)
Non-anatomic superficial tenderness Non-anatomic weakness or sensory loss Simulation tests with axial loading and en bloc rotation producing pain Distraction test or flip test in which pt has no pain with full extension of knee while seated, but the supine SLR is markedly positive Over-reaction verbally or exaggerated body language Waddell, et al. Spine 5(2): , 1980.






62 Hoover Test Helps to determine whether pt is malingering
Should be performed in conjunction with SLR When pt is genuinely attempting to raise leg, he exerts pressure on opposite calcaneus to gain leverage



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