Physical Examination of the Lumbar Spine

1. Physical Examination of the Lumbar Spine Chapter 9

2. Overview Anatomy History Observation Palpation Neurologic exam Circulatory exam Special tests

3. Anatomy Five lumbar vertebrae Five pairs (10 total) facet joints Intricate ligamentous support Anterior & posterior longitudinal Interspinous & supraspinous

4. Anatomy Intervertebral disks Annulus fibrosus Outer zone (Sharpey�s fibers) Intermediate zone Inner zone 20 concentric collar like rings criss-crossed for strength Nucleus pulposus Fluid gradually changes to fibrocartilage

5. Anatomy Erector spinae Latissimus dorsi Obliques Trapezius Segmental muscles Interspinales Intertransversarii Rotatores Abdominals Illiopsoas Hamstrings Quadriceps

6. History: MOI What was the mechanism of injury? Was there a blow to the back? Did you hear or feel anything at time of injury? Was there any neck involvement? Were you twisting or bending at time of injury?

7. History: Pain How did the symptoms begin? How soon after did you feel something? Where is the pain? Is the pain sharp or dull? Constant or intermittent? Localized or diffuse? Aggravated by movement?

8. History: Pain (cont.) Relieved by rest? Are there any abnormal sensations such as numbness, tingling, burning, or radiating pain? Paralysis or paresthesia? Did the symptoms occur right away or later? Do you have any problems sleeping? What type of activity causes pain? Is the pain affected by laughing, coughing, or sneezing?

9. History: Previous injuries Was there any previous injury? What was the assessment? What was the treatment? Were you fully recovered?

10. Observation Deformities Movement and position Signs of trauma Skin color Skin temperature

11. Observation Abnormalities Alignment of neck and back Iliac crest Leg length Scoliosis Winged scapula Forward head

12. Observation Torticollis or wryneck Lordosis Kyphosis Compare Shoulder height

13. Observation Symmetry Muscle spasm ASIS PSIS

14. Observation: ROM Flexion Extension Left and right lateral flexion (�sidebending�) Left and right rotation

15. Palpations: Bone Spinous process Transverse process Scapula SI joint Sacrum Coccyx Iliac crest ASIS PSIS Sciatic notch Ischial tuberosity

16. Palpations: Soft tissue Supraspinous ligaments Infraspinous ligaments Paraspinal muscles Anterior abdominal muscles

17. Neurologic Exam: Sensory Sensory dermatomes C2-C3: Occipital area and angle of jaw C4: Supraclavicular area Axillary Nerve Patch: Lateral aspect of shoulder C5: Lateral upper arm C6: Lateral forearm, thumb, and index finger C7: Middle finger and palmar aspect of hand C8: Small finger, ring finger, and medial portion of palmar surface

18. Neurologic Exam: Sensory Sensory dermatomes T1: Medial side of forearm and elbow T2: Medial aspect of upper arm T3: Medial aspect of upper arm T10: Umbilicus L2: Medial mid-thigh L3: Superior aspect of medial knee (vastus medialis) L4: Knee and medial arch L5: Dorsum of the foot S1: Lateral border and lateral aspect of foot S2: Popliteal fossa

19. Neurologic Exam: Motor C1-C2: Neck flexion C1-C2: Neck extension C3: Neck lateral flexion C4: Shoulder elevation C5: Shoulder abduction and external rotation C6: Elbow flexion and wrist extension C7: Elbow extension and wrist flexion C8: Thumb abduction and ulnar deviation

20. Neurologic Exam: Motor T1: Finger approximation L2: Hip flexion L3: Knee extension L4: Dorsiflexion L5: Great toe extension, ankle dorsiflexion, ankle eversion S1: Plantarflexion S2: Knee flexion

21. Neurologic Exam: Reflexes Biceps (C5-C6) Supinator (C5-C6) Triceps (C7-C8) Upper abdominal (T8-T10) Lower abdominal (T11-T12) Patella (L3-L4) Achilles tendon (S1-S2) Babinski

22. Circulatory Carotid Brachial Radial Femoral Dorsal pedal Posterior tibial

23. Special Tests Neeeeeeeeeeeeext time!