Clinical Examination of the Lumbar Spine

Introduction

• Focus on clinical examination of the lumbar spine.
• Begin in a standing position for posture inspection.

Posture and Alignment

• Pelvic Position:
  • Anteriorly or posteriorly rotated pelvis.
  • Key landmarks: ASIS (Anterior Superior Iliac Spine) and PSIS (Posterior Superior Iliac Spine).
  • Normal anterior rotation is about 15-20 degrees.
  • Excessive anterior rotation may indicate lower cross syndrome.

Range of Motion (ROM) Assessment

• Forward Flexion:

  • Patient bends forward to touch toes.
  • Look for hamstring tightness, lumbar/thoracic spine mobility.
  • Normal range: past the malleoli of the ankles.

• Extension:

  • Patient arches back.
  • Assess comfort, pain, hinge points, and ROM between L1-L5.

• Side Bending:

  • Patient bends to each side.
  • Normal range: reach to at least the fibular head.

• Transverse Plane (Rotation):

  • Patient twists with hips stabilized.
  • Normal range: approximately 60+ degrees.

Palpation of Key Structures

• Iliac Crest and PSIS:

  • Orient for spine location.
  • PSIS helps assess symmetry and potential pelvic rotation.

• Spine Anatomy:

  • Palpate lumbar vertebrae (L1-L5) via spinous processes.
  • Facet joints and transverse processes are palpable lateral to spinous processes.
  • Assess joint play and pain.

Special Tests

• Neural Tension Tests:

  • Straight Leg Raise (SLR): Tests sciatic nerve; positive with nerve symptoms.
  • Kernig's Sign: Intensifies symptoms by chin-to-chest motion.
  • Brudzinski's Sign: Relieves symptoms by flexing the neck.
  • Well Leg Raise: Checks contralateral leg for symptom reproduction.

• Sign of the Buttock:

  • Differentiates between sciatic nerve tension and hip pathology.

• Femoral Nerve Tension Test:

  • For symptoms in the anterior thigh; involves hip extension and knee flexion.

• Val Salva Test:

  • Increases intra-abdominal pressure to test for nerve root compression.

• Slump Test:

  • Seated test for sciatic nerve tension.

• Quadrant Test and Stork Stand Test:

  • Assess facet joint and SI joint dysfunction.

Neurological Testing

• Lower Quarter Screen:
  • Dermatomes: Sensory testing from L2-S2.
  • Myotomes: Muscle strength testing for different spinal levels (L1-S1).
  • Reflexes: Patellar (L3-5) and Achilles tendon (S1-2) reflexes.

Conclusion

• Comprehensive examination involves inspection, palpation, ROM assessment, special tests, and neurological screening.
• Differentiation between referred and radiating pain is crucial.
• Accurate documentation and referral based on findings are important.