Evaluation of The Lumbar Spine

Differential Diagnosis

Most Common

1. Intervertebral Disk Injury

2. Apophyseal Joint injury

3. Stress Fracture of Pars Interarticulars (spondylolysis)

4. Sacroiliac Joint injury

5. Paravertebral Muscle Trigger Points

Less Common

1. Intervertebral Disc Prolapse

2. Spondylolisthesis

3. Lumbar Instability

4. Spinal Canal Stenosis

5. Vertebral Crush Fracture

6. Fibromyalgia

7. Rheumatological

8. Gynecological

9. Gastrointestinal

10. Genitourinary

Not to be Missed

1. Cauda Equina Syndrome

2. Spinal Epidural Abscess

3. Malignancy (primary or metasatic)

4. Osteoid Osteoma

5. Multiple Myeloma

6. Severe Osteoporosis

History

• Location of Pain

• Mechanism of onset

• Radiation to leg or buttocks

• Aggravating or alleviating factors

• Previous history of back problems

• Response to treatment

• Symptoms of cauda equina (bowel or bladder dysfunction)

• Spinal Cord symptoms (difficulty walking, tripping)

• Sensory Symptoms (paresthesia / numbness)

• Motor Symptoms (Muscle weakness)

• Systemic Symptoms (wt loss, malaise, night sweats)

• Night Pain

• History of physical activity is important. Physical workload involving twisting and running are risk factors for sciatica. Jogging is protective. Smoking, mental stress, and job satisfaction are also risk factors for sciatica.85

Examination

Always remember to examine the joint above (Tspine) and below (hip)

Inspection

1. From Behind

2. From Each Side

Palpation

1. Spinous Processes

2. Transverse Processes

3. Apophyseal Joints

4. Sacroiliac Joints

5. Iiolumbar Ligaments

6. Paraspinal Muscles

7. Gluteal Muscles

Motion

Note that range of movement is measured determined actively first, if there is a deficiency, move on to passive range of motion. Any deficits should be measured with a goniometer. Note should be made of discrepence between active and passive movement.

Muscles

Measurement of muscle strength using the Oxford (MRC) Scale.

1. Flexion

2. Extension

3. Rotation

4. Lateral Flexion

NeuroVascular

1. Check and Grade reflexes, sensation, and strength of lower limb nerve roots

2. Check Pulse

3. Rectal tone in suspected Cauda Equina Syndrome

Special Tests for Sciatic Nerve Irritation

1. Straight Leg Raise

2. The Prone Knee Bend Test for Femoral Nerve Stretch

3. Slump Test

Special Tests for Sacroiliac Joint Irritation

1. FABER Test

2. Sacroiliac Compression Test

Special Tests for Spondylolisthesis

1. Jackson Hyperextension Test

Investigations

1. Plain Films: Indicated for acute trauma, stress fractures, suspected spondylolisthesis, or suspected lumbar instability. Consider Xray in non-responsive back pain.

2. Bone Scan: May be helpful to diagnose spondylolysis or stress fractures.

3. CT may be performed for suspected nerve root symptoms, however it has low specificity. Also helpful for suspected spinal stenosis or facet joint arthropathy. It may also confirm a part interarticularis defect.

4. MRI: Very sensitive but poorly specific. Capable of confirming annular tear or disc disease. The investigator must confirm clinically: an abnormality on MRI is not necessarily responsible for the back pain.

5. Myelography: May be helpful for operative planning for disc herniation.

6. Discography: Dye is injected into the nucleus pulposis of the disc. Pain on exam confirms the diagnosis. The test may confirm the structure of the disk. This is the best true diagnostic test for discogenic back pain.

Index

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