Anatomy and Physical Examination of the Lower Back

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Anatomy and Physical Examination of the Lower Back

• Sports Medicine Fellowship
• Uniformed Services University of the Health
  Sciences

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Objectives

• Review the functional anatomy of Lumbar spine
• Review Physical Examination of LS spine
• Correlate clinico-pathologic dx with pertinent
  physical findings

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Epidemiology of back pain

• The most common musculoskeletal disorder in
  industrialized societies
• Second only to common cold as cause of lost work
  time
• Estimated that 80 of population will
  experience at least one disabling episode of back
  pain at some time during their lifetime
• The most common cause of disability in persons
  under the age of 45

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Epidemiology of back pain (cont.)

• When compensation from lost work, long-term
  disability, and medical and legal expenses are
  considered, is the most costly of all medical dxs

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PATIENT HISTORY OPQRSTU

• Onset
• Palliative/Provocative factors
• Quality
• Radiation
• Severity/Setting in which it occurs
• Timing of pain during day
• Understanding - how it affects the patient

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Red Flags in back pain

• Hx of cancer
• Unrelenting nocturnal pain
• Weight loss
• Fever, chills, night sweats
• Age lt 15 or gt 50
• Neurologic deficits
• Decreased motor and/or sensory innervation
• Urinary and/or fecal incontinence

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Anatomy

• Vertebra
• Body, anteriorly
• Functions to support weight
• Vertebral arch, posteriorly
• Formed by two pedicles and two laminae
• Functions to protect neural structures

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Vertebral arch

• 7 vertebral processes arise from vertebral arch
• 3 lever-like processes - provide attachments
  sites for ligaments and muscles
• Spinous process
• 2 Transverse processes
• 4 articular processes
• Arise from junction of pedicle and laminae

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Vertebral Arch

• Space enclosed by body and vertebral arch is the
  vertebral foramen
• Successive vertebral foramen form the vertebral
  canal

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Ligaments

• Anterior longitudinal ligament
• Posterior longitudinal ligament
• Interspinous ligament
• Supraspinous ligament
• Ligamentum flavum

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Intervertebral Disc

• Most common site of back pain
• Normally comprises 25 of length of spine
• Consists of a central nucleus pulposus
• Reticulated and collagenous substance
• Composed of 88 water
• Annulus fibrosus
• Consists of concentric lamellae of fibrocartilage
  fibers arranged obliquely
• With each layer, they are arranged in opposite
  directions

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Facet Joint

• Formed by articulation of inferior and superior
  processes of subsequent vertebrae
• Orientation in lumbar spine is toward sagittal
  plane, allowing flexion and extension but
  limiting rotation of the lumbar vertebrae
• Helps to prevent anterior movement of superior
  vertebra on inferior vertebra
• Articular surfaces are made up of noninnervated
  articular cartilage
• Capsule and synovial membrane are innervated with
  pain receptors

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Physical Examination

• Inspection
• Palpation
• Bony
• Soft Tissue
• Range of Motion
• Neurologic Examination
• Special Tests

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Inspection

• Observe for areas of erythema
• Infection
• Long-term use of heating element
• Unusual skin markings
• Café-au-lait spots
• Neurofibromatosis
• Hairy patches (Fauns beard)
• Lipomata
• Spina bifida

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Inspection (cont.)

• Posture
• Shoulders and pelvis should be level
• Bony and soft-tissue structures should appear
  symmetrical
• Normal lumbar lordosis
• Exaggerated lumbar lordosis is common
  characteristic of weakened abdominal wall

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Bone Palpation

• Palpate L4/L5 junction (level of iliac crests)
• Palpate spinous processes superiorly and
  inferiorly
• S2 spinous process at level of posterior superior
  iliac spine
• Absence of any sacral and/or lumbar processes
  suggests spina bifida
• Visible or palpable step-off indicative of
  spondylolisthesis

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ANTERIOR PALPATION
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Soft Tissue Palpation

• 4 clinical zones
• Midline raphe
• Paraspinal muscles
• Gluteal muscles
• Sciatic area
• Anterior abdominal wall and inguinal area

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Range of Motion

• Flexion
• Extension
• Lateral Bending
• Rotation

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Flexion - 80º Extension - 35º Side bending -
40º each side Twisting - 3-18º
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Neurologic Examinaion

• Includes an exam of entire lower extremity, as
  lumbar spine pathology is frequently manifested
  in extremity as altered reflexes, sensation and
  muscle strength
• Describes the clinical relationship between
  various muscles, reflexes, and sensory areas in
  the lower extremity and their particular cord
  levels

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Neurologic Examination(T12, L1, L2, L3 level)

• Motor
• Iliopsoas - main flexor of hip
• With pt in sitting position, raise thigh against
  resistance
• Reflexes - none
• Sensory
• Anterior thigh

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Neurologic Examination(L2, L3, L4 level)

• Motor
• Quadriceps - L2, L3, L4, Femoral Nerve
• Hip adductor group - L2, L3, L4, Obturator N.
• Reflexes
• Patellar - supplied by L2, L3, and L4, although
  essentially an L4 reflex and is tested as such

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L2, L3, L4 testing
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Neurologic Examination(L4 level)

• Motor
• Tibialis Anterior
• Resisted inversion of ankle
• Reflexes
• Patellar Reflex (L2, L3, L4)
• Sensory
• Medial side of leg

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Neurologic Examination(L5 level)

• Motor
• Extensor Hallicus Longus
• Resisted dorsiflexion of great toe
• Reflexes - none
• Sensory
• Dorsum of foot in midline

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Neurologic Examination(S1 level)

• Motor
• Peroneus Longus and Brevis
• Resisted eversion of foot
• Reflexes
• Achilles
• Sensory
• Lateral side of foot

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Special Tests

• Tests to stretch spinal cord or sciatic nerve
• Tests to increase intrathecal pressure
• Tests to stress the sacroiliac joint

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Tests to Stretch the Spinal Cord or Sciatic Nerve

• Straight Leg Raise
• Cross Leg SLR
• Kernig Test

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Test to increase intrathecal pressure

• Valsalva Maneuver
• Reproduction of pain suggestive of lesion
  pressing on thecal sac

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Tests to stress the Sacroiliac Joint

• Pelvic Rock Test
• FABER Test

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Flexion A- Bduction External Rotation
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Non-organic Physical Signs(Waddells signs)

• Non-anatomic superficial tenderness
• Non-anatomic weakness or sensory loss
• Simulation tests with axial loading and en bloc
  rotation producing pain
• Distraction test or flip test in which pt has no
  pain with full extension of knee while seated,
  but the supine SLR is markedly positive
• Over-reaction verbally or exaggerated body
  language

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Hoover Test

• Helps to determine whether pt is malingering
• Should be performed in conjunction with SLR
• When pt is genuinely attempting to raise leg, he
  exerts pressure on opposite calcaneus to gain
  leverage

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Common Causes of Low Back Pain

• Muscular spasm, strain
• Ligament sprain
• Spondylosis
• Herniated nucleus pulposus
• Facet joint dysfunction
• Spondylo-lysis or -listhesis
• Seronegative spondyloarthropathies

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Clearing up the terms

• Spondylosis
• Degenerative joint disease affecting the
  vertebrae and intervertebral disc
• Spondylolysis
• Fracture in pars interarticularis
• Spondylolisthesis
• Displacement of one vertebra on another

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Disc rupture and herniation
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Spondylo-lysis and -listhesis
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Facet joint pain
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Ankylosing spondylitis
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