1. Anatomy and Physical Examination of the Lower Back
Sports Medicine Fellowship
Uniformed Services University of the Health Sciences

2. Objectives Review the functional anatomy of Lumbar spine
Review Physical Examination of LS spine
Correlate clinico-pathologic dx with pertinent physical findings

4. 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

5. 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

6. 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
Onset
Palliative/Provocative factore
Quality
Radiation
Severity/Setting in which it occurs
Timing of pain during day
Understanding - how it affects the patient

7. “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

8. Anatomy Vertebra Body, anteriorly Functions to support weight
Vertebral arch, posteriorly
Formed by two pedicles and two laminae
Functions to protect neural structures

9. 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

10. Vertebral Arch
Space enclosed by body and vertebral arch is the vertebral foramen
Successive vertebral foramen form the vertebral canal

12. Ligaments Anterior longitudinal ligament
Posterior longitudinal ligament
Interspinous ligament
Supraspinous ligament
Ligamentum flavum

14. 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

16. 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

19. Physical Examination Inspection Palpation Bony Soft Tissue
Range of Motion
Neurologic Examination
Special Tests

20. 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

22. 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

25. 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

29. Common area of pain due to low back sprains or the avulsion of a tendon from the posterior superior iliac spines

30. ANTERIOR PALPATION ANTERION PALPATION
Anteriorly, umbilicus lies at L3-L4 disc space, the point where aorta divides into common iliacs
Anterior portions of L4, L5, and S1 vertebral bodies and discs are palpable below the aorta’s division

31. Soft Tissue Palpation 4 clinical zones Midline raphe
Paraspinal muscles
Gluteal muscles
Sciatic area
Anterior abdominal wall and inguinal area

32. Palpate as a unit on either side of midline
Note any tenderness, spasm, defects, or dissimilarity

34. Sciatic nerve exits pelvis thru greater sciatic foramen under the piriformis muscle
Midway between the greater trochanter and ischial tuberosity
To palpate the sciatic nerve, have pt flex hip, and locate the midpoint
Herniated disc or lesion compressing the nerve roots can cause tenderness to palpation

35. Have pt perform abdominal crunch, then palpate each segment of rectus abdominis, noting any weakness or deficit
Abdominal muscles are segmental and receive segmental innervation
Pain in inguinal area usually indicates pathology in hip joint

37. Range of Motion
Flexion
Extension
Lateral Bending
Rotation

41. Flexion - 80º
Extension - 35º
Side bending - 40º each side
Twisting º

42. 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

43. 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

44. 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

45. L2, L3, L4 testing

46. Neurologic Examination (L4 level)
Motor
Tibialis Anterior
Resisted inversion of ankle
Reflexes
Patellar Reflex (L2, L3, L4)
Sensory
Medial side of leg

47. L4 LEVEL
Motor: Tibialis Anterior
-Resisted inversion of ankle
Reflexes: Patellar Reflex
Sensory: L4 dermatome covers medial side of leg

48. Neurologic Examination (L5 level)
Motor
Extensor Hallicus Longus
Resisted dorsiflexion of great toe
Reflexes - none
Sensory
Dorsum of foot in midline

49. L5 LEVEL
Motor: Extensor Hallicus Longus
-Resisted dorsiflexion of great toe
Reflexes - none
Sensory: Dorsum of foot in midline

50. Neurologic Examination (S1 level)
Motor
Peroneus Longus and Brevis
Resisted eversion of foot
Reflexes
Achilles
Sensory
Lateral side of foot

51. S1 LEVEL:
Motor: Peroneus Longus and Brevis
-Resisted eversion of foot
Reflexes: Achilles
Sensory: Lateral side of foot

52. Special Tests Tests to stretch spinal cord or sciatic nerve
Tests to increase intrathecal pressure
Tests to stress the sacroiliac joint

53. Tests to Stretch the Spinal Cord or Sciatic Nerve
Straight Leg Raise
Cross Leg SLR
Kernig Test

56. Test to increase intrathecal pressure
Valsalva Maneuver
Reproduction of pain suggestive of lesion pressing on thecal sac

58. Tests to stress the Sacroiliac Joint
Pelvic Rock Test
FABER Test

60. Flexion A-
Bduction
External
Rotation

61. Non-organic Physical Signs (“Waddell’s signs”)
Non-anatomic superficial tenderness
Non-anatomic weakness or sensory loss
Simulation tests with axial loading and en bloc rotation producing pain
Distraction test or flip test in which pt has no pain with full extension of knee while seated, but the supine SLR is markedly positive
Over-reaction verbally or exaggerated body language
Waddell, et al. Spine 5(2): , 1980.

67. Hoover Test Helps to determine whether pt is malingering
Should be performed in conjunction with SLR
When pt is genuinely attempting to raise leg, he exerts pressure on opposite calcaneus to gain leverage

70. Common Causes of Low Back Pain
Muscular spasm, strain
Ligament sprain
Spondylosis
Herniated nucleus pulposus
Facet joint dysfunction
Spondylo-lysis or -listhesis
Seronegative spondyloarthropathies

71. Clearing up the terms Spondylosis
Degenerative joint disease affecting the vertebrae and intervertebral disc
Spondylolysis
Fracture in pars interarticularis
Spondylolisthesis
Displacement of one vertebra on another

72. Disc rupture and herniation

75. Spondylo-lysis and -listhesis

79. Facet joint pain

81. Ankylosing spondylitis