Lumbar Spine Examination video

Lumbar Spine Exam

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

A gentle lordosis is normal. Exaggerated lordosis is seen in hip flexor contracture, weak hip extensors, spondylolisthesis.

Posterior examiantion

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.

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

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. Response: Normal motion of the lumbar spine should be atleast 4-5 cm. 

Describe the tests useful in diagnosing lumbar disc herniation?

SLR

Elevation of the leg is stopped when patient begins to feel any pain. 

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. 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

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

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. Waddell signs (mnemonic - ROADS)

Patient may complain of numbness involving the entire extremity, entrire leg, leg below the knee, quarter or half of the body.  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. 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. 

• 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.

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Posted in: Neurology/Neurosurgery,Orthopedic