Lumbar Spine Anatomy & Physical Exam Adrienne Sekerak MPAS, PA-C Center for Spine Health Cleveland Clinic Foundation Low Back Pain 70-80% of the population experiences low back pain at some point in time Second leading cause of missed work days (common cold is #1) Prevalent in all aspects of medicine Mainstay of treatment is non-operative
Economic Impact of Pain More than $50 million in lost productivity from employee absences is due to pain Pain costs an estimated $100 billion annually American Pain Foundation. Fast facts about pain. Available at: www.painfoundation.org./page_fastfacts.asp. L1-L5, Left Lateral View
Lumbar Anatomy 5 Vertebrae kidney shaped Increase in size Superior articular process Pedicles, Lamina
Intervertebral Disc Nucleus Pulposus (NP) Annulus Fibrosus (AF) Cartilaginous Endplate (CEP) NP Chondrocytic Phenotype Loose Matrix, Proteoglycan AF Fibroblastic Phenotype Matrix: Rich in Collagen Lumbar Spine Exam: Visual Inspection/Palpation General Inspection- note obvious abnormality Skin- scars, sinuses, or color change Soft Tissue- swelling, spasms Palpation: areas of pain, tenderness, swelling
Inspection https://www.youtube.com/watch?v=c4drwou8g8e Lumbar Spine Exam: Visual Inspection Normal Spine Exam: Cervical Lordosis Thoracic Kyphosis Lumbar Lordosis
Lumbar Exam: Posture & Lumbar ROM Gait Motor Sensory DTRs SLR Lumbar ROM: Lateral Flexion Flexion and Extension Rotation- occurs mainly in thoracic spine
GAIT Tandem gait/ heel-to-toe walk Walk on heels Walk on toes Gait Antalgic Gait: Avoiding pain. https://www.youtube.com/watch?v=w-s8pk63yre Neuropathic (steppage) Gait: https://www.youtube.com/watch?v=jzjipy6vrlo
Lumbar Spine: Motor Body Positioning- Note paralysis or weakness Involuntary movements- tics, tremors, fasciculations Muscle Tone- flaccid, clonic, normal & appearance Muscle Strength- 5/5 normal Lumbar Spine: Motor 0- No muscle contraction detected 1- A trace contraction is noted 2- Able to actively move muscle when gravity eliminated 3- move muscle against gravity, not against resistance 4- move muscle group against some resistance 5- moves muscle group and overcomes resistance
Lumbar Spine: Motor Iliopsoas muscles : test the flexion of the hip by asking the patient to lie down and raise each leg separately while you provide resistance. Hip flexion is innervated by the L2 and L3 nerve roots via the femoral nerve. Lumbar Spine: Motor Test the abduction of the legs by placing your hands on the outer thighs and asking the patient to move their legs apart. This tests the gluteus maximus and gluteus minimus. Abduction of the hip is mediated by the L4, L5 and S1 nerve roots.
Lumbar Spine: Motor Test the adduction of the legs by placing your hands on the inner thighs of the patient and asking them to bring both legs together. This tests the adductors of the medial thigh. Adduction of the hip is mediated by the L2, L3 and L4 nerve roots. Lumbar Spine: Motor Test extension at the knee by placing one hand under the knee and the other on top of the lower leg to provide resistance. Ask the patient to "kick out" or extend the lower leg at the knee. Repeat and compare to the other leg. This tests the quadriceps muscle. Knee extension by the quadriceps muscle is innervated by the L3 and L4 nerve roots via the femoral nerve.
Lumbar Spine: Motor Next, test the extension of the hip by instructing the patient to press down on the examiner's hand which is placed underneath the patient's thigh. Repeat and compare to the other leg. This tests the gluteus maximus. Hip extension is innervated by the L4 and L5 nerve roots via the gluteal nerve. Lumbar Spine: Motor Test flexion at the knee by holding the knee from the side and applying resistance under the ankle and instructing the patient to pull the lower leg towards their buttock as hard as possible. This tests the hamstrings. The hamstrings are innervated by the L5 and S1 nerve roots via the sciatic nerve.
Lumbar Spine: Motor Test dorsiflexion of the ankle by holding the top of the ankle and have the patient pull their foot up towards their face as hard as possible. Repeat with the other foot. This tests the muscles in the anterior compartment of the lower leg. Ankle dorsiflexion is innervated by the L4 and L5 nerve roots via the peroneal nerve. Lumbar Spine: Motor Holding the bottom of the foot, ask the patient to "press down on the gas pedal" as hard as possible. Repeat with the other foot and compare. This tests the gastrocnemius and soleus muscles in the posterior compartment of the lower leg. Ankle plantar flexion is innervated by the S1 and S2 nerve roots via the tibial nerve.
Lumbar Spine: Motor To complete the motor exam of the lower extremity ask the patient to move the large toe against resistance "up towards the patient's face". The EHL muscle is almost completely innervated by the L5 nerve root. This tests the extensor halucis longus muscle. Lumbar Exam: Sensory Pain Sensation- Pin Prick (PP) Light Touch Sensation- A Brush Position Sense
Dermatomes An area of the skin that is supplied by a single spinal nerve root Symptoms that follow a dermatome indicate a pathology at that specific nerve root Lumbar Exam: Sensory Corresponding Nerve Root: 1. Upper part of the upper leg (L2) 2. Lower-medial part of upper leg (L3) 3. Medial lower leg (L4) 4. Lateral lower leg (L5) 5. Sole of foot (S1)
Lumbar Spine: DTRs 5+ sustained clonus 4+ very brisk, hyperreflexic, w/clonus 3+ brisker, more reflexic than normal 2+ normal 1+ low normal, diminished 0.5+ elicited with reinforcement 0 no response Lumbar Spine: DTRs The knee jerk reflex is mediated by the L3 and L4 nerve roots, mainly L4. The ankle jerk reflex is mediated by the S1 nerve root
Lumbar Spine: DTRs LONG TRACT SIGNS: Test the Babinski's reflex- indicative of an upper motor neuron lesion affecting the lower extremity in question. Test clonus if any of the reflexes appeared hyperactive Reflexes https://www.youtube.com/watch?v=jk0js2osvka
Adult Scoliosis Degenerative Scoliosis 3D deformity secondary to degenerative changes overlap with adolescent idiopathic scoliosis that progresses during adulthood Adult Scoliosis age > 18 Rigid curves Spinal imbalance due to limited compensatory capacity male:female = 1:1 etiology; uncertain progression = 1 degree/year
Spinal Deformity KYPHOS- Sharp posterior convexity KYPHOSIS- Gradual curve Adult causes of Kyphosis Developmental Schuermann s Degenerative Posttraumatic Osteoporotic spine fractures Tumor Inflammatory Infection Iatrogenic
Kyphosis Operative Treatment, Case Example 20 y/o male Progressive kyphosis despite bracing Upper back pain Neurologically intact Kyphosis Pre- and Post-op xrays
Spinal Deformity LORDOSIS- is an increased curving of the spine.
Mechanical vs Neuropathic Pain Mechanical Pain Degenerative changes Gets worse with activity Localized in back rarely radiates past knee. Does NOT cause weakness/numbness Neuropathic Pain Nerve injury Symptoms are where the nerve travels causes weakness/numbness reflexes slow, muscles weaken? Primary Muscle Dz Observe pt rising out of a chair Note Proximal muscle weakness Pts c/o- can't get out of the car easily, need help getting off couch.
Axial Pain Back Dominant Worse pain is in the low back Frequently radiates to buttock May radiate to thighs/legs Usually in a non-radicular diffuse pattern Lumbar Spine: Exam https://www.youtube.com/watch?v=c4d RwoU8g8E
Radicular Pain Leg Dominant Pain worse in the leg vs back Radicular pattern (specific dermatome) May include buttock Lumbar Disk Syndromes & Lumbosacral Radics: L3/L4 Disc Prolapse: Pain anterior thigh Wasting of quads may be present Diminished sensation anterior thigh & medial lower leg Reduced knee jerk reflex
Lumbar Disk Syndromes & Lumbosacral Radiculitis L4/L5 Disc Prolapse: Pain along posterior or posterolateral thigh Numbness or tingling at the top of foot and great toe Weakness of dorsiflexion of great toe and foot No reflex changes noted Lower Back Syndromes/ Radiculopathies: L5/S1 Disc Prolapse: Pain along posterior thigh, radiates into heel Weakness of plantar flexion (may be absent) Sensory loss in the lateral foot Absent ankle jerk reflex
Myelopathy Symptomatic Compression of the spinal cord Upper Motor Neuron screening Hyper-reflexia Babinski response Clonus > 4 beats / Sustained clonus Spasticity Bowel/Bladder Including Hx of retention, frequency (no other cause ID d), incontinence Need to do a post void residual PVR catheterization (> 100cc abnormal) Cauda Equina Syndrome Symptomatic Compression of the Cauda Equina Bowel/Bladder/Erectile Dysfunction Including Hx of retention, frequency (no other cause ID d), incontinence Need to do a post void residual PVR catheterization (> 100cc abnormal) Saddle Anaesthesia / Dysesthesia Motor Disturbance