import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, ContentSection, SpecialTestCard , MedicalImage} from '@/components/content' # Lumbar Spine Examination The lumbar spine examination must identify radiculopathy, exclude cauda equina syndrome, and differentiate between mechanical pain, disc herniation, and spinal stenosis. The straight leg raise is the key provocative test. Always ask about bladder function. ## Quick Reference One-Pager ## Introduction and Setup **Patient Positioning:** - Standing for inspection and movements - Supine for SLR and neurological examination - Prone for femoral stretch and palpation **Exposure:** Back exposed from neck to buttocks, lower limbs for neurological examination **Consent Script:** "I'm going to examine your lower back. I'll start by watching you move, then examine you lying down. I'll need to test the strength and sensation in your legs. Please tell me if anything causes pain." **Key Anatomy:** - 5 lumbar vertebrae, sacrum, coccyx - Lumbar nerve roots exit BELOW corresponding vertebra (L4 root exits at L4-5 level) - Conus medullaris ends at L1-2, cauda equina below - Common disc levels: L4-5 (L5 root), L5-S1 (S1 root) ## Red Flags (Screen First) **CAUDA EQUINA SYNDROME - SURGICAL EMERGENCY:** - **Bilateral leg symptoms**: Pain, weakness, or numbness - **Saddle anesthesia**: Numbness in perianal region, buttocks - **Bladder dysfunction**: Retention, incontinence, poor stream - **Bowel dysfunction**: Fecal incontinence - **Progressive neurological deficit**: Especially bilateral **Other Red Flags:** - Age under 20 or over 55 with new symptoms - Constant, non-mechanical pain (worse at night) - Thoracic pain - History of malignancy - Constitutional symptoms (fever, weight loss) - IV drug use - Immunosuppression - Structural deformity - Bilateral symptoms or signs ## Look (Inspection) - **Scoliosis**: Structural vs antalgic (sciatic list) - **Muscle bulk**: Paraspinal wasting, gluteal wasting - **Skin**: Hairy patch, dimple (spina bifida), café au lait spots - **Alignment**: Shoulders/pelvis level - **Scars**: Previous surgery - **Lumbar lordosis**: Normal, flattened (spasm), increased - **Thoracic kyphosis**: Scheuermann's, ankylosing spondylitis - **Hip flexion**: Compensatory in fixed flexion deformity - **Posture**: Forward lean - **Antalgic gait**: Short stance phase on painful side - **Trendelenburg gait**: L5 weakness (hip abductors) - **Foot drop gait**: High-stepping (L5 weakness) - **Wide-based gait**: Spinal stenosis with neurogenic claudication **Sciatic List (Antalgic Scoliosis):** The patient leans away from the side of a lateral disc herniation to decompress the nerve root. This is a compensatory posture, not a structural scoliosis, and corrects when the disc pathology resolves. ## Feel (Palpation) **Posterior Midline:** 1. **L1-L5 spinous processes**: Step-off (spondylolisthesis), tenderness 2. **Sacrum**: S1, S2 3. **Coccyx**: Tenderness (coccydynia) **Posterior Lateral:** 1. **Paraspinal muscles**: Spasm, tenderness 2. **Quadratus lumborum**: Deep lateral 3. **Iliac crest**: Reference point, greater than 4cm below = L4 4. **PSIS**: Posterior superior iliac spine **SI Joint Region:** 1. **SI joint**: Tenderness (sacroiliitis) 2. **Greater sciatic notch**: Sciatic nerve (piriformis syndrome) **Landmarks:** - Iliac crests are level with L4 spinous process - PSIS are level with S2 - Tuffier's line (intercristal line) for lumbar puncture at L4-5 ## Move (Range of Motion) ## Special Tests ### Tension Signs (Nerve Root Stretch) ### Other Tests ## Neurological Assessment | Root | Muscle | Action | Test | |------|--------|--------|------| | L2 | Iliopsoas | Hip flexion | Resisted hip flexion | | L3 | Quadriceps | Knee extension | Resisted knee extension | | L4 | Tibialis anterior | Ankle dorsiflexion | Heel walking | | L5 | EHL, Gluteus medius | Great toe extension, Hip abduction | Toe extension, Trendelenburg | | S1 | Gastrocnemius, Peronei | Ankle plantarflexion, Eversion | Toe walking | | S2 | Hamstrings | Knee flexion | Resisted knee flexion | | Root | Area | |------|------| | L2 | Anterior thigh | | L3 | Medial thigh above knee | | L4 | Medial leg and foot (medial malleolus) | | L5 | Lateral leg, dorsum of foot, great toe | | S1 | Lateral foot, sole, lateral malleolus | | S2 | Posterior thigh | | S3-5 | Perianal (saddle area) - ALWAYS CHECK | | Reflex | Root | Technique | |--------|------|-----------| | Knee jerk | L3,4 | Tap patellar tendon | | Ankle jerk | S1 | Tap Achilles tendon | | Babinski | UMN | Plantar surface stroke | | Anal wink | S2-4 | Perianal scratch (CES screening) | | Bulbocavernosus | S2-4 | Squeeze glans, feel anal contraction | **L5 vs S1 Radiculopathy - Key Differentiators:** | Feature | L5 Root | S1 Root | |---------|---------|---------| | Pain distribution | Lateral leg, dorsum foot | Posterior calf, lateral foot, sole | | Motor weakness | EHL, ankle dorsiflexion, hip abduction | Plantarflexion, eversion | | Sensory loss | Dorsum foot, great toe | Lateral foot, sole | | Reflex change | None (or slightly reduced ankle jerk) | Ankle jerk diminished/absent | | Common disc | L4-5 | L5-S1 | ## Vascular Assessment - **Femoral**: Groin, below inguinal ligament - **Popliteal**: Posterior knee (deep) - **Dorsalis pedis**: Dorsum of foot - **Posterior tibial**: Behind medial malleolus **Claudication History:** - Vascular: Cramping in calf, relieved by rest in any position - Neurogenic: Aching/burning in thighs and legs, relieved by flexion (sitting, leaning forward) ## Complete the Examination **Always state to the examiner:** "To complete my examination, I would like to: - Examine the **hips** to exclude referred pain - Examine the **SI joints** if indicated - Check **peripheral pulses** (vascular claudication) - Perform **rectal examination** if cauda equina suspected - Obtain **X-rays** (AP, lateral) and **MRI** if indicated" ## Summary Presentation ## Common Conditions Table ## Waddell's Signs (Non-Organic Back Pain) 1. **Tenderness**: Superficial, non-anatomical (whole back) 2. **Simulation**: Pain on axial loading or rotation without spinal movement 3. **Distraction**: Discrepancy between sitting and supine SLR (Flip test) 4. **Regional disturbance**: Non-dermatomal sensory/motor changes 5. **Overreaction**: Disproportionate verbal or physical response **Interpretation:** - 3 or more positive categories suggest non-organic component - Does NOT mean the patient is malingering - may indicate distress - Consider psychological assessment ## Examiner Tips