Lumbar Spine
Look
From front – are the shoulders level?
From side – look for kyphosis and lordosis.Are these normal? Exaggerated?
- Loss of lordosis – degenerative disc disease
- Exaggerated Lordosis :
- Spondylolisthesis – where one vertebra has moved anteriorly relative to the one below it. Most commonly occurs in the lumbar spine.
- Fixed flexion deformity in the hips
- Pregnancy
- Obesity
From Back – any scoliosis, check shoulder level again. Look for any scars, and any wasting of the paraspinal muscles.
Feel
Move
Lateral flexion – ask the patient to stand up straight with their hands down by their sides. Then ask them to lean to their left sliding the left arm towards their knee. Do the same on the right.
Forward flexion – ask the patient to touch their toes, or reach as far as they can.
- Shober’s test – this is a quantitative assessment of flexion of the lumbar spine. There are several variations. Essentially, with the patient stood upright, you should find the dimples of venus near the base of the lumbar spine. Imagine a line between these, and put a dot along this line. Then measure 10cm above this line, and mark another dot. Then ask the patient to touch their toes (or as far as they can). Whilst in this position, re-measure this distance between your two dots. It should be >15cm – ie. The distance should have increased by 5cm or more.
- In another variation, you should measure 5cm below the dimples of venus, and mark a dot 15cm above this point. Then check that the distance increases to >20cm on flexion.
- In a positive test, the distance is increases by <5cm. This is commonly caused by ankylosing spondylitis.
Extension – Make sure you are able to support the patient if necessary. Ask them to lean backwards, whilst keeping their hips in place. -/span>
Rotation – Easiest if you stand behind the patient and put your hands on their hips. Then ask them to look over their shoulder
Special tests
Sciatic nerve stretch test – aka – straight leg raiseask the patient to lie on their back on the couch. The couch should be flat. Raise the leg of the bed (flexion of the hip). This should not elicit any pain whilst the leg raise is within normal limits. If it does elicit pain, note the site at which pain is elicited, then, lower the leg, until it is back below the site of pain. One the leg is in this position, then dorsiflex the foot – if the pain is the result of sciatica – this will elicit pain again
- The straight leg raise in itself can result in pain from many causes (bursitis, hamstring damage). Dorsiflexing the foot helps isolate the sciatic nerve as the test. Applying pressure to the popliteal fossa also helps to anchor the sciatic nerve and may increase the sensitivity of the test where there is only mild sciatic nerve involvement.
- Result of herniation of the L4/L5 or L5/S1 discs
- Patients will have symptoms of lower leg, and buttocks
Femoral nerve stretch test herniation at L3-4– ask the patient to lie prone (on their front). The extend the hip, and flex the knee to 90’. Pain felt at the back of the thigh indicates femoral nerve involvement.
- Result of herniation of discs higher up the lumbar spine
- Patients will have symptoms of anterior thigh (inc weakness and pain)
