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Anatomy and Physical Examination of the Lower Back

Anatomy and Physical Examination of the Lower Back. Sports Medicine Fellowship Uniformed Services University of the Health Sciences. Objectives . Review the functional anatomy of Lumbar spine Review Physical Examination of LS spine

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Anatomy and Physical Examination of the Lower Back

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  1. Anatomy and Physical Examination of the Lower Back Sports Medicine Fellowship Uniformed Services University of the Health Sciences

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

  3. 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

  4. 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 dx’s

  5. 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

  6. “Red Flags” in back pain • Hx of cancer • Unrelenting nocturnal pain • Weight loss • Fever, chills, night sweats • Age < 15 or > 50 • Neurologic deficits • Decreased motor and/or sensory innervation • Urinary and/or fecal incontinence

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

  8. Ligaments • Anterior longitudinal ligament • Posterior longitudinal ligament • Interspinous ligament • Supraspinous ligament • Ligamentum flavum

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

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

  11. 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

  12. 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

  13. ANTERIOR PALPATION

  14. Soft Tissue Palpation • 4 clinical zones • Midline raphe • Paraspinal muscles • Gluteal muscles • Sciatic area • Anterior abdominal wall and inguinal area

  15. Range of Motion • Flexion • Extension • Lateral Bending • Rotation

  16. Flexion - 80º Extension - 35º Side bending - 40º each side Twisting - 3-18º

  17. 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

  18. 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

  19. 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

  20. L2, L3, L4 testing

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

  22. Neurologic Examination(L5 level) • Motor • Extensor Hallicus Longus • Resisted dorsiflexion of great toe • Reflexes - none • Sensory • Dorsum of foot in midline

  23. Neurologic Examination(S1 level) • Motor • Peroneus Longus and Brevis • Resisted eversion of foot • Reflexes • Achilles • Sensory • Lateral side of foot

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

  25. Tests to Stretch the Spinal Cord or Sciatic Nerve • Straight Leg Raise • Cross Leg SLR • Kernig Test

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