Nellis Primary Care Sports Medicine Lumbar Spine Pain

Physical exam

Inspection

Skin changes (rash, erythema, etc) Absence of lordosisScoliosisPelvic asymmetry/tilt

Palpation for Tenderness

Spinous process Paraspinous musclesSI joints

ROM

Lumbar FlexionLumbar Extension

**Strength in Lumbar/Spinal N distribution (weakness?)

Knee Extension (L3)Ankle Inversion/Dorsiflexion (L4) Great-Toe dorsiflexion (L5)Ankle Eversion/Plantarflexion (S1)

**Neurovascular exam (abnormal DTR?)

Patellar reflex (L4) Achilles (S1) Saddle Anesthesia

**Sensation (decreased/compare each side)

Medial Ankle (L4)Dorsum Foot (L5)Lateral Foot/Sole (S1)

Special Tests

Neural-tension tests Slump Test Straight Leg Raise (bilat)SI Joint Patrick's (FABER) test Gaenslen's Test CompressionSingle Leg Stork TestTrendelenberg Test

Lumbar spondylosis *Lumbar Spondylolisthesis*Lumbar SpondolysisHerniated disc (HNP)

**HNP with myelopathy HNP with radiculopathy Spinal Stenosis Fracture

Rheumatoid arthritis **Tumor

**Osteomyelitis/Discitis **Epidural abscess

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Adapted 2012 with permission from Original Work by Drs. Ashwin Rao and Jonathan Drezner 2007; Dr. Jeff Leggit 2016

-Numbness or tingling?-Aggravating/Alleviating factors?-Pain with motion or positions?-Increased pain with cough, sneeze, valsalva?-Worse with forward bending?-Effect on activity, work, exercise-Previous treatment? (Specific!!)-Systemic symptoms present?

History elements to ask

-Mechanism of injury (Trauma or No)?-Acute traumatic, overuse, or spontaneous onset?-Location of pain (butt, hip, 1-sided, central)-Radiation to buttocks, legs, feet?-Activity during the previous 2 months prior to pain?-Prior injury/surgery?

DDX Based on Anatomy and the above testing

Know the Basic Anatomy!

Here are a few...List NOT inclusive** = Don't Miss

Lumbar Spine Assessment

Remember: In the L-spine the nerve rootexits BELOW the vertabrae it is name for. i.e. the L4 nerve root exits BELOW the L4 vertebra at the L4-5

level.

Figure 3: The Sacroiliac joint. This image demonstrates the SI joint’s location in respect to the entire pelvis.

Figure 2: Herniated Nucleus pulposus (HNP). Here, the herniated disc is shown to

impinge upon a nerve root.

Figure 6: Spondylolysis: Bilateral fractures of the pars interarticularis causes vertebral slippage

(spondylolisthesis). This may be demonstrated on x-rays or MRI.

Figure 4: Straight-Leg Raise: Passively raise the affected leg with the knee locked. Pain in the low back radiation down the leg at 30deg of hip

flexion is a positive test finding

Figure 5: Slump test. The examiner passively dorsiflexes the patient’s foot, while keeping

the neck in flexion. Pain and/or discomfort in the low back or leg suggests neural tension.

Figure 9 – The Single Leg Stork Test. Patient stands on one leg while extending spin

maximally. Pain in lumbar region on stance leg suggests spondylolisthesis (stress fracture of the

spine) Figure 7: Gaenslen's test. The examiner

passively flexes contralateral hip while extending affected hip (off table). Pain and/or discomfort in area of the SI joint is positive.

Figure 8: SI compression test