1. Evaluation of the Lumbar Spine By B.Nelson

2. Overview At some time in their lives, 80% of the general population will experience some type of low back pain (LBP) - it is second only to the common cold as a reason for physician visits, and the most expensive source of compensated work related injury in modern industrialized countries Despite the frequency of LBP and the many studies examining LBP, LBP is a difficult problem to investigate and several key issues concerning its occurrence, natural history and prognosis remain unanswered

3. Outline of Presentation The lumbar spine supports the upper body and transmits the weight of the body to the pelvis and lower limb Unless there is a definite history of trauma, there is a difficulty to determine whether the symptoms originate in the hip,LS or SI joint

4. LBP-Natural history 90% LBP resolves without medical attention in 6-12 weeks 50% LBP resolves within 1 year Even 75% sciatica resolves within 6mo Recurrence may be 80% within 1 year (Frymoyer JW. Back pain and sciatica. N Engl J Med 1988;318:291-300) (Vanharanta H.Etiology, epidemiology and natural history of lumbar disc disease. Spine State Art Rev 1989;3:1-12)

5. Anatomy The lumbar spine consists of 5 lumbar vertebrae Between each of the lumbar vertebrae is the intervertebral disc (IVD) The articulations between two consecutive lumbar vertebrae form three joints – One joint is formed between the two vertebral bodies and the intervertebral disc (IVD) – The other two joints are formed by the articulation of the superior articular process of one vertebra and the inferior articular processes of the vertebra above.

6. Lumbosacral spine 5 weight bearing Lumbar vertebrae Atypical: Sacralized L5 Complete -1% Incomplete -6% Atypical: Lumbarized S1 => L6 about 4%

7. Anatomy Vertebra – In general, the lumbar vertebrae increase in size from L 1 to L 5 in order to accommodate progressively increasing loads

8. Anatomy Ligaments – Anterior longitudinal ligament (ALL) Extends from the sacrum along the anterior aspect of the entire spinal column, becoming thinner as it ascends – Posterior longitudinal ligament (PLL) Found throughout the spinal column, where it covers the posterior aspect of the centrum and IVD

9. Anatomy Ligaments – Ligamentum flavum (LF) Connects two consecutive laminae – Interspinous ligament Connects two consecutive spinal processes – Supraspinous Ligament Connects the tips of two adjacent spinous processes

10. Anatomy Muscles – Quadratus Lumborum The importance of this muscle from a rehabilitation viewpoint is its contribution as a lumbar spine stabilizer – Lumbar multifidus (LM) The lumbar multifidus is an important muscle for lumbar segmental stability through its ability to provide segmental stiffness and control motion

11. Anatomy Muscles – Erector spinae The erector spinae is a composite muscle consisting of the iliocostalis lumborum and the thoracic longissimus. Both of these muscles are subdivided into the lumbar and thoracic longissimii and iliocostallii

12. Anatomy Muscles – Thoracolumbar fascia (TLF) Assists the in transmission of extension forces during lifting activities Stabilizes the spine against anterior shear and flexion moments

13. Examination The physical examination of the lumbar spine must include a thorough assessment of the neuromuscular, vascular and orthopedic systems of the hip, lower extremities, low back and pelvic regions

14. Evaluation of low back pain HISTORY Location of pain Mechanism of onset Degree of irritability Radiation Aggravating and relieving factors Associated features-sensory, motor

15. Examination History – The clinician should establish the chief complaint of the patient, in addition to the location, behavior, irritability, and severity of the symptoms – Although dysfunctions of the lumbar spine are very difficult to diagnose, the history can provide some very important clues

16. Examination Systems Review – It must always be remembered that pain can be referred to the lumbar spine area from pathological conditions in other regions

17. Examination Observation – Observation involves an analysis of the entire patient as to how they move, and respond in addition to the positions they adopt – Although spinal alignment provides some valuable information, a positive correlation has not been made between abnormal alignment and pain

18. Inspection Normal Posture – Shoulders and pelvis level – Bony and soft tissue symmetric – 1 = Cervical lordosis – 2 = Thoracic kyphosis – 3 = Lumbar lordosis – 4 = Sacral kyphosis

19. Inspection Abnormal Posture (Standing) – Listing to one side: sciatic scoliosis (herniated disc) – Lumbar lordosis absent: paravertebral muscle spasm – Extremely sharp kyphosis: Gibbus Deformitiy – Exaggerated lumbar lordosis: weak abd wall muscles

20. Examination Palpation – Whenever it is performed, palpation of the lumbar spine area should be performed in a systematic manner, and should be performed in conjunction with palpation of the hip and pelvic area

21. Bony Palpation: Posterior Iliac crest L4-5, count spinous processes above L4-5 reference point Posterior superior iliac spines (PSIS) Greater trochanters Ischial tuberosities Coccyx: rectal exam

22. Bony Palpation Posterior: Abnormal Spondylolisthesis – “Step off” – Forward slippage of process onto another, L5 on S1 or L4 on L5 Spondolysis (pars interarticularis defect), seen in gymnasts and fast bowers, tennis, high jump, throwing athletes Coccydynia – Tailbone pain, usually result of direct blow or fall Spina bifida – Gaps between or missing lumbar or sacral spinous processes

23. Examination Active range of motion – Normal active motion, which demonstrates considerable variability between individuals, involves fully functional contractile and inert tissues, and optimal neurological function – It is the quality of motion and the symptoms provoked, rather than the quantity of motion that is more important

24. Flexion 40 to 60 degrees

25. Extension 20 to 35 degrees

26. Lateral Bending 15 to 20 degrees

27. Rotation 3 to 18 degrees

28. Examination Key muscle tests – The key muscle tests examine the integrity of the neuromuscular junction and the contractile and inert components of the various muscles – With the isometric tests, the contraction should be held for at least five seconds to demonstrate any weakness – If the clinician suspects weakness, the test is repeated 2-3 times to assess for fatiguability, which could indicate spinal nerve root compression.

29. ASIA Dermatomes L3 medial knee L4 medial shin L5 great toe S1 lateral heel/ lateral foot S2 posterior knee

30. Straight Leg RaiseTest (lower plexus) Normal test: ankle of elevation > 70 degrees with only mild discomfort/hamstring tightness Stretches: L5, S1 nerve roots (w/ little tension on proximal nerves) Positive test: reproduces pain along distribution of sciatic nerve Sensitivity: 90% Specificity: 25% Neural Tension Tests Straight leg Raise Test

31. Fabere (Patrick) Test Hip and SI joint test Patient supine Hip flexed, abducted, externally rotated +inguinal pain: hip Press on knee and opposing hip +back pain: SI joint

32. Thomas Test Hip flexion contracture

33. Suggested text Orthopaedic Physical Assessment by David Magee Orthopaedic Medicine by Monica Kesson and Elaine Atkins Living Surface Anatomy by Philip Harris and Craig Ranson