Lumbar SpineOrthopedic 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.

Pars fracture is most common at the L5 level, but can occur in other lumbar vertebra and in the thoracic spine as well.

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

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

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.

Spinal Percussion Test

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/CompressionNeurogenic 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/CompressionIntraspinal 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/CompressionClinical 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

Procedure: Patient supine. Raise the patient’s leg to a point of pain or 90 °, whichever comes first.

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.

Straight Leg Raising 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.

Lasegue’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.

Bragard’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

Bechterew’s Test

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.

Minor’s 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)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 lateral 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 medial 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.

Antalgic Lean (Disc protrusion central to

nerve root)

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.

Kemp’s Test

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 Lesions

Clinical Signs and SymptomsLower back pain

Lower extremity radicular pain

Lower extremity weakness

Loss of lower extremity reflexes

Loss of lower extremity sensation

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.

Valsalva’s Maneuver

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 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

Clinical Signs and Symptoms:Lower back pain

Sacroiliac joint painAggravated by sitting

Alleviated by standing or walking

Lower extremity radicular pain

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.

Goldthwaith’s 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.

Nachlas Test