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Lumbar Spine. Orthopedic Tests. Lumbar Anatomy. Erector Spinae Group. Quadratus Lumborum. Gluteal Muscles. Spondylolysis. A defect of the vertebral body with NO forward movement of one vertebra on another. A defect of the pars interarticularis.

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lumbar spine

Lumbar Spine

Orthopedic Tests

spondylolysis
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.
spondylolisthesis
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.
spondylolisthesis grades
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
spinal percussion test
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.
referred pain vs radicular pain
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.
lumbar nerve root sciatic nerve irritation compression
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.
lumbar nerve root sciatic nerve irritation compression13
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.
lumbar nerve root sciatic nerve irritation compression14
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
straight leg raising test
Straight Leg Raising Test
  • Procedure: Patient supine. Raise the patient’s leg to a point of pain or 90 °, whichever comes first.
straight leg raising test16
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.
lasegue s test
Lasegue’s Test
  • Procedure: Patient supine. Flex the patient’s 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.
bragard s test
Bragard’s 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.
bechterew s test
Bechterew’s 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
minor s sign
Minor’s 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.
antalgic lean sign
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.
antalgic lean disc protrusion lateral to nerve root
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.
antalgic lean disc protrusion medial to nerve root
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.
antalgic lean disc protrusion central to nerve root
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.
kemp s test
Kemp’s 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.
space occupying lesions
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.
space occupying lesions36
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
valsalva s maneuver
Valsalva’s 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.
dejerine s triad
Dejerine’s 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.
lumbar vs sacroiliac joint involvement
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.
sacroiliac joint syndrome
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
goldthwaith s test
Goldthwaith’s 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.
nachlas test
Nachlas Test
  • Procedure: Patient prone. Approximate the patient’s 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.