Transcript Evaluation of the Lumbar Spine

Evaluation of the Lumbar Spine
Outline of Presentation
• Overview
• Anatomy
• Steps in the evaluation of the LS
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
Overview
• 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)
Overview
• 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
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.
Lumbosacral spine
• 5 weight bearing Lumbar
vertebrae
• Atypical: Sacralized L5
Complete -1%
Incomplete -6%
• Atypical: Lumbarized S1
=> L6 about 4%
Anatomy
• Vertebra
– In general, the lumbar vertebrae increase in size
from L 1 to L 5 in order to accommodate
progressively increasing loads
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
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
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
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
Anatomy
• Muscles
– Thoracolumbar fascia (TLF)
• Assists the in transmission of extension forces during
lifting activities
• Stabilizes the spine against anterior shear and flexion
moments
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
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
Evaluation of low back pain
HISTORY
•Location of pain
•Mechanism of onset
•Degree of irritability
•Radiation
•Aggravating and relieving factors
•Associated features-sensory, motor
Examination
• Systems Review
– It must always be remembered that pain can be
referred to the lumbar spine area from
pathological conditions in other regions
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
Inspection
• Normal Posture
– Shoulders and pelvis level
– Bony and soft tissue symmetry
– 1 = Cervical lordosis
– 2 = Thoracic kyphosis
– 3 = Lumbar lordosis
– 4 = Sacral kyphosis
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
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
Bony Palpation: Posterior
• Iliac crest L4-5, count spinous processes above
L4-5 reference point
• Posterior superior iliac spines (PSIS)
• Spinous processes
• Tranverse processes
• Sacroiliac joint
• Paraspinal muscles
• Gluteal muscles
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
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
Flexion
• 40 to 60 degrees
Extension
• 20 to 35 degrees
Lateral Bending
• 15 to 20 degrees
Rotation
• 3 to 18 degrees
Passive Range of movement
• Difficult to carryout PROM of the LS
• Over pressure may be applied at the end of
AROM
Resisted Muscle testing
• Performed in a neutral position with the
patient seated to stabilise the hip
• Instruction “do not let me move you”
• Flexion ,extension, side flexion, rotation
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.
Lower limb scan
•
•
•
•
Hip joint
Knee joint
Ankle joint
Foot
Special tests
• Straight Leg Raise /Lasegue test- used to
assess tight hams or irritation of sciatic nerve
• Slump test- to assess lumbar nerve root
compression
• Sacroiliac Joint test/Faber test – assess the SI
jt
Special Tests cont’d
• Dynamic abdominal endurance test
• Prone knee bend test- stresses the femoral
nerve and L2- L4 nerve root
• Stork test – to detect stress injury in the
posterior elements of the lumbar spine
Neurological examination
Myotomes
•
•
•
•
•
•
L2 – Hip flexion
L3 – knee extension
L4– Dorsiflexion
L5- Extension of great toe
S1- ank plantflexion
S2- knee flexion
Neural Tension Tests
Straight leg Raise Test
Straight Leg RaiseTest
(lower plexus)
 Normal test: angle 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%
Faber (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
ASIA Dermatomes
•
•
•
•
L3 medial knee
L4 medial shin
L5 great toe
S1 lateral heel/
lateral foot
• S2 posterior knee
References
• Orthopaedic Physical Assessment by David
Magee
• Orthopaedic Medicine by Monica Kesson and
Elaine Atkins
• Living Surface Anatomy by Philip Harris and
Craig Ranson