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

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Presentation on theme: "Anatomy and Physical Examination of the Lower Back Sports Medicine Fellowship Uniformed Services University of the Health Sciences."— Presentation transcript:

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

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

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

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

6 PATIENT HISTORY “OPQRSTU” l Onset l Palliative/Provocative factors l Quality l Radiation l Severity/Setting in which it occurs l Timing of pain during day l Understanding - how it affects the patient

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

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

9 Vertebral arch l 7 vertebral processes arise from vertebral arch –3 lever-like processes - provide attachments sites for ligaments and muscles l Spinous process l 2 Transverse processes –4 articular processes l Arise from junction of pedicle and laminae

10 Vertebral Arch l Space enclosed by body and vertebral arch is the vertebral foramen l Successive vertebral foramen form the vertebral canal

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12 Ligaments l Anterior longitudinal ligament l Posterior longitudinal ligament l Interspinous ligament l Supraspinous ligament l Ligamentum flavum

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14 Intervertebral Disc l Most common site of back pain l Normally comprises ~ 25% of length of spine l Consists of a central nucleus pulposus –Reticulated and collagenous substance –Composed of ~ 88% water l Annulus fibrosus –Consists of concentric lamellae of fibrocartilage fibers arranged obliquely –With each layer, they are arranged in opposite directions

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16 Facet Joint l Formed by articulation of inferior and superior processes of subsequent vertebrae l Orientation in lumbar spine is toward sagittal plane, allowing flexion and extension but limiting rotation of the lumbar vertebrae l Helps to prevent anterior movement of superior vertebra on inferior vertebra l Articular surfaces are made up of noninnervated articular cartilage l Capsule and synovial membrane are innervated with pain receptors

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19 Physical Examination l Inspection l Palpation –Bony –Soft Tissue l Range of Motion l Neurologic Examination l Special Tests

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

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

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

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30 ANTERIOR PALPATION

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

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37 Range of Motion l Flexion l Extension l Lateral Bending l Rotation

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41 Flexion - 80º Extension - 35º Side bending - 40º each side Twisting - 3-18º

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

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

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

45 L2, L3, L4 testing

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

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

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

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

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

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

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58 Tests to stress the Sacroiliac Joint l Pelvic Rock Test l FABER Test

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60 Flexion A- Bduction External Rotation

61 Waddell, et al. Spine 5(2):117-125, 1980. Non-organic Physical Signs (“Waddell’s signs”) l Non-anatomic superficial tenderness l Non-anatomic weakness or sensory loss l Simulation tests with axial loading and en bloc rotation producing pain l 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 l Over-reaction verbally or exaggerated body language

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

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70 Common Causes of Low Back Pain l Muscular spasm, strain l Ligament sprain l Spondylosis l Herniated nucleus pulposus l Facet joint dysfunction l Spondylo-lysis or -listhesis l Seronegative spondyloarthropathies

71 Clearing up the terms l Spondyl osis –Degenerative joint disease affecting the vertebrae and intervertebral disc l Spondylo lysis –Fracture in pars interarticularis l Spondylo listhesis –Displacement of one vertebra on another

72 Disc rupture and herniation

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75 Spondylo-lysis and -listhesis

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79 Facet joint pain

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81 Ankylosing spondylitis

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