Lumbar Spine

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Lumbar Spine

• Orthopedic Tests

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Lumbar Anatomy
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Erector Spinae Group
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Quadratus Lumborum
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Gluteal Muscles
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Spondylolysis

• A defect of the vertebral body with NO forward
  movement of one vertebra on another.
• A defect of the pars interarticularis.
• Pars fracture is most common at the L5 level, but
  can occur in other lumbar vertebra and in the
  thoracic spine as well.

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Spondylolisthesis

• A defect of the vertebra with forward movement of
  one vertebra on another.
• The defect of the pars interarticularis allows
  ofr the forward migration of one vertebra on
  another.

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Spondylolisthesis Grades

• Grade 1 0-25 forward movement
• Grade 2 25-50 forward movement
• Grade 3 50-75 forward movement
• Grade 4 75-100 forward movement

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Spinal Percussion Test

• Procedure Patient seated. Bent slightly
  forward. Tap the spinous processes and
  associated musculature with a reflex hammer.
• Positive Test Local pain fracture without
  neurological compromise. Radicular pain
  fracture or disc defect with neurological
  compromise. Pain in paraspinal musculature
  muscle strain.

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Spinal Percussion Test
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Referred Pain Vs. Radicular Pain

• Lower extremity pain may be referred from
  lumbopelvic tissues or viscera. It may also be
  radicular pain from the nerve roots of the spine.
• Referred pain patterns the spinal pain is more
  aggravating than the lower extremity pain.
  Referred pain is poorly localized and dull.
• Radicular pain patterns the leg pain is more
  aggravating than the spinal pain. Radicular pain
  is sharp and well localized.

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Lumbar Nerve Root Sciatic Nerve
Irritation/Compression

• Neurogenic radicular lower extremity pain may be
  caused by any one of several factors.
• Tension, irritation, or compression of a lumbar
  nerve root or roots can cause radicular pain.

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Lumbar Nerve Root Sciatic Nerve
Irritation/Compression

• Intraspinal canal compressions disc lesions,
  spinal stenosis, degenerative disc disease,
  hypertrophic changes, malignancy.
• Extraspinal canal compressions muscle
  dysfunction, extradural defects, masses.

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Lumbar Nerve Root Sciatic Nerve
Irritation/Compression

• Clinical Signs and Symptoms
• Lower back pain
• Lower extremity radicular pain
• Loss of lower extremity reflexes
• Loss of lower extremity muscle strength
• Loss of lower extremity sensation

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Straight Leg Raising Test

• Procedure Patient supine. Raise the patients
  leg to a point of pain or 90 , whichever comes
  first.

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Straight Leg Raising Test

• Positive Test This test stresses the sciatic
  nerve and spinal nerve roots L5, S1, and S2.
• Pain after 70 of hip flexion lumbar joint
  pain.
• Pain at 35 to 70 sciatic nerve roots tense
  pain due to IVD pathology.
• Pain between 0 to 35 extradural sciatic
  involvement (spastic piriformis, SI joint
  lesion).
• Dull posterior thigh pain tight hamstring.

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Straight Leg Raising Test
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Lasegues Test

• Procedure Patient supine. Flex the patients
  hip with the leg flexed. Keeping the hip flexed,
  extend the leg.
• Positive Test Positive test for sciatic
  radiculopathy occurs when
• (a) no pain is elicited when the hip is flexed
  and the leg is flexed.
• (b) pain is present when the hip is flexed and
  the leg is extended.

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Lasegues Test
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Bragards Test

• Procedure Patient supine. Raise leg to point
  of pain. Lower the leg 5 and dorsiflex the
  foot.
• Positive Test Pain due to traction of the
  sciatic nerve.
• Pain with dorsiflexion at 0 to 35 extradural
  sciatic nerve irritation.
• Pain with dorsiflexion from 35 70
  intradural problem (usually IVD lesion).
• Dull posterior thigh pain tight hamstring.

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Bragards Test
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Bechterews Test

• Procedure Patient seated with legs hanging off
  the examination table. Patient extend one knee
  at a time. If no response, then extend both
  together.
• Positive Test Extending the leg puts traction
  on the sciatic nerve. Positive test if patient
  cannot perform test due to pain or if patient
  leans back. Indicates disc protrusion.
• 1, 2 Bechterew

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Bechterews Test
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Minors Sign

• Procedure Instruct the seated patient to stand.
• Positive Test The patient with sciatic
  radiculopathy will stand on the healthy side and
  keep the affected leg flexed.

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Minors Sign
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Antalgic Lean Sign

• Procedure Observe the patient while standing.
• Patients with disc protrusions that place
  pressure on a nerve root will lean in a direction
  that reduces the mechanical pressure on the disc.

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Antalgic Lean (Disc protrusion lateral to nerve
root)

• Positive Sign If the disc protrusion is lateral
  to the nerve root, the patient will lean away
  from the side of pain.
• Leaning away pulls the nerve root medially away
  from the disc defect and relieves pain.

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Antalgic Lean (Disc protrusion lateral to nerve
root)
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Antalgic Lean (Disc protrusion medial to nerve
root)

• Positive Sign If the disc protrusion is medial
  to the nerve root, the patient will lean toward
  the side of pain.
• Leaning towards the side of the lesion pulls the
  nerve laterally away from the disc defect,
  reducing pressure on the nerve root.

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Antalgic Lean (Disc protrusion medial to nerve
root)
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Antalgic Lean (Disc protrusion central to nerve
root)

• Positive Sign If the disc protrusion is central
  to the nerve root, the patient may assume a
  flexed posture.
• Leaning forward puts the posterior portion of the
  disc under traction, which can reduce the surface
  area of the disc that comes into contact with the
  nerve.

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Antalgic Lean (Disc protrusion central to nerve
root)
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Kemps Test

• Procedure Patient seated or standing.
  Stabilize the PSIS with one hand. Reach around
  the patient with the other hand and passively
  bend the dorsolumbar spine obliquely backward.
• Positive Test Pain in the lower back is a
  positive test for lumbar spasm or facet
  capsulitis. Radicular pain suggests a disc
  lesion.

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Kemps Test
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Space-Occupying Lesions

• Space-occupying lesions can consist of the
  following
• Disc defect, degenerative change, synovial cyst,
  fracture, tumor, or some combination of these
  factors.
• Space-occupying lesions can lead to spinal
  stenosis.
• Narrowing of the tubular structures of the spine.
• Naorrowing of the central canal, lateral recess,
  or intervertebral foramen.

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Space-Occupying Lesions

• Clinical Signs and Symptoms
• Lower back pain
• Lower extremity radicular pain
• Lower extremity weakness
• Loss of lower extremity reflexes
• Loss of lower extremity sensation

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Valsalvas Maneuver

• Procedure Instruct the seated patient to bear
  down as if straining at stool. Concentrate the
  stress at the lumbar region. Ask if pain is
  increased and have the patient point to it.
• Positive Test The test increases intrathecal
  pressure.
• Positive test indicates a space-occupying lesion.
  

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Valsalvas Maneuver
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Dejerines Triad

• Procedure Patient seated. Instruct the patient
  to cough, sneeze, and bear down as if straining
  at stool.
• Positive Test Increased local pain suggests a
  space-occupying lesion.

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Lumbar Vs. Sacroiliac Joint Involvement

• Lumbar and/or radicular pain in the leg can be
  caused by either a lumbar condition or by a
  sacroiliac joint condition.
• The following tests help to differentiate between
  the two sources of pain.

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Sacroiliac Joint Syndrome

• Clinical Signs and Symptoms
• Lower back pain
• Sacroiliac joint pain
• Aggravated by sitting
• Alleviated by standing or walking
• Lower extremity radicular pain

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Goldthwaiths Test

• Procedure Patient supine. Place one hand under
  the lumbar spine with each finger under an
  interspinous space. With the other hand perform
  a straight leg raising test.
• Positive Test Radicular pain before the fanning
  out of the lumbar vertebra indicates an
  extradural lesion such as a sacroiliac joint
  lesion. Radicular pain during lumbar fanning
  indicates an intradural lesion such as a
  space-occupying lesion. Local pain after lumbar
  fanning indicates a posterior lumbar joint
  disorder.

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Goldthwaiths Test
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Nachlas Test

• Procedure Patient prone. Approximate the
  patients heel to the buttock on the same side.
• Positive Test Stretches the femoral nerve
  (largest branch of the lumbar plexus). Radicular
  pain to the anterior thigh compression or
  irritation of the L2 L4 nerve roots by an
  intradural lesion. Pain in the buttock SI
  joint lesion. Pain in the lumbosacral joint
  lumbosacral lesion.

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Nachlas Test