880 likes | 1.03k Views
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
E N D
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 • Correlate clinico-pathologic dx with pertinent physical findings
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
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
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
“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
Anatomy • Vertebra • Body, anteriorly • Functions to support weight • Vertebral arch, posteriorly • Formed by two pedicles and two laminae • Functions to protect neural structures
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
Vertebral Arch • Space enclosed by body and vertebral arch is the vertebral foramen • Successive vertebral foramen form the vertebral canal
Ligaments • Anterior longitudinal ligament • Posterior longitudinal ligament • Interspinous ligament • Supraspinous ligament • Ligamentum flavum
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
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
Physical Examination • Inspection • Palpation • Bony • Soft Tissue • Range of Motion • Neurologic Examination • Special Tests
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
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
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
Soft Tissue Palpation • 4 clinical zones • Midline raphe • Paraspinal muscles • Gluteal muscles • Sciatic area • Anterior abdominal wall and inguinal area
Range of Motion • Flexion • Extension • Lateral Bending • Rotation
Flexion - 80º Extension - 35º Side bending - 40º each side Twisting - 3-18º
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
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
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
Neurologic Examination(L4 level) • Motor • Tibialis Anterior • Resisted inversion of ankle • Reflexes • Patellar Reflex (L2, L3,L4) • Sensory • Medial side of leg
Neurologic Examination(L5 level) • Motor • Extensor Hallicus Longus • Resisted dorsiflexion of great toe • Reflexes - none • Sensory • Dorsum of foot in midline
Neurologic Examination(S1 level) • Motor • Peroneus Longus and Brevis • Resisted eversion of foot • Reflexes • Achilles • Sensory • Lateral side of foot