examination of the lumbar spine

clues

· walking / mobility aids

· external appliances

· lumbar brace

· AFO

Look

From front

· stand patient facing you

General

· manifestations of systemic disease

· face

· skin

· height and habitus

Contour

Wasting

· quadriceps

from lateral side

· turn patient side on

Deformity

· normal

· there is a thoracic kyphosis and a lumbar lordosis

· abnormal

· exaggerated

· reduced

from back

· turn patient facing away from you

Deformity

· scoliosis

· shoulder height

· scapular symmetry

· flank contour

· loin creases

· PSIS height (leg length)

· legs

· symmetry of stance

Skin

· scars

· pigmentation

· dimple or hairy patch

Contour

Swelling

· paravertebral spasm

Wasting

· buttocks

· thighs

· calves

Move

Forward flexion

· perform simultaneously

Forward flexion test

· standing with feet together and knees straight

· aiming to touch floor

· comment on

· pain

· amount (fingertips in relation to front of legs)

Schobar’s test

· thumb on LS junction

· line joining dimples of Venus

· reconfirms level pelvis

· index finger 10 cm above

· width of hand

· amount of increased separation of fingers on spine

· should be at least 50%

Extension

· from flexed position

· pain

· difficulty (hands on thighs)

· extension catch

· hyperextension

· one hand in small of back and one hand on shoulder

· amount (15^o-30^o)

Lateral flexion

· from midline

· one hand on hip and other hand on shoulder

· pain

· amount (15^o-30^o)

Rotation

· feet still and twist body

· look from above

· angle between plane of shoulders and pelvis

· amount (45^o)

gait

· walk away from you

· walk towards you

· on tiptoes

· on heels

· walk beside patient to steady them

· squat

lying prone

Feel

Spine

· palpation

· down middle

· down each side

· comment on

· malalignment

· step

· defect

· percussion

· tenderness

SI joints

· palpate

· tenderness

Buttock

· tenderness

· masses

Move

Femoral stretch test

· steady pelvis with one hand

· test hip extension range first

· lift leg with knee straight (hand under knee)

· then stretch femoral nerve

· flex knee to 90 degrees

· grasp ankle with other hand and lift

· positive if reproduces leg pain

· in distribution of femoral nerve

(Ankle jerk)

· with knee flexed to 90^o

on lateral side

Abductor power

· lift leg up

· palpate contraction

· grade power

SI joint

· semilateral position

· leg flexed and adducted across body

· forced adduction

lying supine

Straight leg raise

Hip ROM

· flex hip to 90^o and rotate hip

· comment

· painless range of hip movement

Lasegue

· lift leg from bed with knee straight

· note when pain occurs

· at what angle of hip flexion

· note where pain is

· back or leg

· same as usual pain

· in distribution of sciatic nerve

· differentiate from tight hamstrings

Dorsiflexion (sciatic stretch)

· lower leg until pain just disappears

· forcibly dorsiflex foot and assess if pain recurs

Bowstring

· hand in popliteal fossa

· slightly flex knee

· apply pressure to medial and lateral hamstrings

· apply pressure to nerve in popliteal fossa

· comment if reproduces pain

Power

· put joint into desired position

· palpate muscle

· ask patient to maintain position against you

Hip

· hip adduction (L2,3)

· squeeze knees together

· hip abduction (L4,5,1)

· push legs apart

· hip flexion (L2,3)

· pull knee to chest

· hip extension (L4,5)

· push knee away

Knee

· knee flexion (L5,S1)

· pull heel to bottom

· knee extension (L3,4)

· hold knee straight

Foot

· ankle dorsiflexion (L4, 5)

· pull foot up

· hallux dorsiflexion (L5)

· pull big toe up

· ankle plantarflexion (S1,2)

· push foot down

· hallux plantarflexion (S1,2)

· push big toe down

· ankle inversion (L4)
hold foot in

· ankle eversion (L5,S1)

· hold foot out

Reflexes

· knee jerk (L4)

· flex knee slightly

· ankle jerk (S1)

· flex knee and ankle to 90^o in midair OR

· tap on soles

· Babinski

· scratch soles

Sensation

· light touch

· L1 (groin)

· L2 (proximal lateral thigh)

· L3 (medial distal thigh and knee)

· L4 (medial calf)

· L5 (lateral calf, dorsum of foot and medial toes)

· S1 (sole and lateral toes)

· S2 (posterior calf and thigh)

· S3,4 ('bulls-eye' around perineum)

Special

circulation

· pulses

· assess proximally if foot pulses absent

cephalad

· hip joint

· ROM

Other

Ankylosing spondylitis

· wall test

· stand with back to wall

· heels, buttocks and occiput touch wall

· SI joint

· SI stress test

· chest expansion

· measure inspiratory and expiratory difference

· should be > 5 cm

Kyphosis

· forward bending test

· observe from side

· correction test

· hyperextension while prone

Leg length

· correction

· blocks and reassess curve

· sitting

· reassess curve