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Functional Anatomy - Uniformed Services University of the Health

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Anatomy and Physical Examination
of the Lower Back
Sports Medicine Fellowship
Uniformed Services University of the Health Sciences
Objectives
Review the functional anatomy of Lumbar spine
пЃ¬ Review Physical Examination of LS spine
пЃ¬ Correlate clinico-pathologic dx with pertinent
physical findings
пЃ¬
Epidemiology of back pain
The most common musculoskeletal disorder in
industrialized societies
пЃ¬ Second only to common cold as cause of lost
work time
пЃ¬ Estimated that ~ 80% of population will
experience at least one disabling episode of back
pain at some time during their lifetime
пЃ¬ The most common cause of disability in persons
under the age of 45
пЃ¬
Epidemiology of back pain (cont.)
пЃ¬
When compensation from lost work, long-term
disability, and medical and legal expenses are
considered, is the most costly of all medical dx’s
PATIENT HISTORY
“OPQRSTU”
Onset
пЃ¬ Palliative/Provocative factors
пЃ¬ Quality
пЃ¬ Radiation
пЃ¬ Severity/Setting in which it occurs
пЃ¬ Timing of pain during day
пЃ¬ Understanding - how it affects the patient
пЃ¬
“Red Flags” in back pain
Hx of cancer
пЃ¬ Unrelenting nocturnal pain
пЃ¬ Weight loss
пЃ¬ Fever, chills, night sweats
пЃ¬ Age < 15 or > 50
пЃ¬ Neurologic deficits
– Decreased motor and/or sensory innervation
– Urinary and/or fecal incontinence
пЃ¬
Anatomy
пЃ¬
Vertebra
– Body, anteriorly
пЃ¬ Functions to support weight
– Vertebral arch, posteriorly
пЃ¬ Formed by two pedicles and two laminae
пЃ¬ Functions to protect neural structures
Vertebral arch
пЃ¬
7 vertebral processes arise from vertebral arch
– 3 lever-like processes - provide attachments
sites for ligaments and muscles
пЃ¬ Spinous process
пЃ¬ 2 Transverse processes
– 4 articular processes
пЃ¬ Arise from junction of pedicle and laminae
Vertebral Arch
Space enclosed by body and vertebral arch is the
vertebral foramen
пЃ¬ Successive vertebral foramen form the vertebral
canal
пЃ¬
Ligaments
Anterior longitudinal ligament
пЃ¬ Posterior longitudinal ligament
пЃ¬ Interspinous ligament
пЃ¬ Supraspinous ligament
пЃ¬ Ligamentum flavum
пЃ¬
Intervertebral Disc
Most common site of back pain
пЃ¬ Normally comprises ~ 25% of length of spine
пЃ¬ Consists of a central nucleus pulposus
– Reticulated and collagenous substance
– Composed of ~ 88% water
пЃ¬ Annulus fibrosus
– Consists of concentric lamellae of
fibrocartilage fibers arranged obliquely
– With each layer, they are arranged in opposite
directions
пЃ¬
Facet Joint
Formed by articulation of inferior and superior
processes of subsequent vertebrae
пЃ¬ Orientation in lumbar spine is toward sagittal
plane, allowing flexion and extension but limiting
rotation of the lumbar vertebrae
пЃ¬ Helps to prevent anterior movement of superior
vertebra on inferior vertebra
пЃ¬ Articular surfaces are made up of noninnervated
articular cartilage
пЃ¬ Capsule and synovial membrane are innervated
with pain receptors
пЃ¬
Physical Examination
Inspection
пЃ¬ Palpation
– Bony
– Soft Tissue
пЃ¬ Range of Motion
пЃ¬ Neurologic Examination
пЃ¬ Special Tests
пЃ¬
Inspection
Observe for areas of erythema
– Infection
– Long-term use of heating element
пЃ¬ Unusual skin markings
– Café-au-lait spots
пЃ¬ Neurofibromatosis
– Hairy patches (Faun’s beard)
– Lipomata
пЃ¬ Spina bifida
пЃ¬
Inspection (cont.)
Posture
– Shoulders and pelvis should be level
– Bony and soft-tissue structures should appear
symmetrical
пЃ¬ Normal lumbar lordosis
– Exaggerated lumbar lordosis is common
characteristic of weakened abdominal wall
пЃ¬
Bone Palpation
Palpate L4/L5 junction (level of iliac crests)
пЃ¬ Palpate spinous processes superiorly and
inferiorly
– S2 spinous process at level of posterior superior
iliac spine
пЃ¬ Absence of any sacral and/or lumbar processes
suggests spina bifida
пЃ¬ Visible or palpable step-off indicative of
spondylolisthesis
пЃ¬
ANTERIOR PALPATION
Soft Tissue Palpation
пЃ¬
4 clinical zones
– Midline raphe
– Paraspinal muscles
– Gluteal muscles
– Sciatic area
– Anterior abdominal wall and inguinal area
Range of Motion
Flexion
пЃ¬ Extension
пЃ¬ Lateral Bending
пЃ¬ Rotation
пЃ¬
Flexion - 80Вє
Extension - 35Вє
Side bending - 40Вє each side
Twisting - 3-18Вє
Neurologic Examinaion
Includes an exam of entire lower extremity, as
lumbar spine pathology is frequently manifested
in extremity as altered reflexes, sensation and
muscle strength
пЃ¬ Describes the clinical relationship between
various muscles, reflexes, and sensory areas in the
lower extremity and their particular cord levels
пЃ¬
Neurologic Examination
(T12, L1, L2, L3 level)
Motor
– Iliopsoas - main flexor of hip
– With pt in sitting position, raise thigh against
resistance
пЃ¬ Reflexes - none
пЃ¬ Sensory
– Anterior thigh
пЃ¬
Neurologic Examination
(L2, L3, L4 level)
Motor
– Quadriceps - L2, L3, L4, Femoral Nerve
– Hip adductor group - L2, L3, L4, Obturator N.
пЃ¬ Reflexes
– Patellar - supplied by L2, L3, and L4, although
essentially an L4 reflex and is tested as such
пЃ¬
L2, L3, L4 testing
Neurologic Examination
(L4 level)
Motor
– Tibialis Anterior
пЃ¬ Resisted inversion of ankle
пЃ¬ Reflexes
– Patellar Reflex (L2, L3, L4)
пЃ¬ Sensory
– Medial side of leg
пЃ¬
Neurologic Examination
(L5 level)
Motor
– Extensor Hallicus Longus
– Resisted dorsiflexion of great toe
пЃ¬ Reflexes - none
пЃ¬ Sensory
– Dorsum of foot in midline
пЃ¬
Neurologic Examination
(S1 level)
Motor
– Peroneus Longus and Brevis
– Resisted eversion of foot
пЃ¬ Reflexes
– Achilles
пЃ¬ Sensory
– Lateral side of foot
пЃ¬
Special Tests
пЃ¬ Tests
to stretch spinal cord or sciatic
nerve
пЃ¬ Tests to increase intrathecal pressure
пЃ¬ Tests to stress the sacroiliac joint
Tests to Stretch the Spinal Cord or
Sciatic Nerve
пЃ¬ Straight
Leg Raise
пЃ¬ Cross Leg SLR
пЃ¬ Kernig Test
Test to increase intrathecal
pressure
пЃ¬ Valsalva
Maneuver
–Reproduction of pain suggestive of
lesion pressing on thecal sac
Tests to stress the Sacroiliac Joint
пЃ¬ Pelvic
Rock Test
пЃ¬ FABER Test
Flexion
ABduction
External
Rotation
Non-organic Physical Signs
(“Waddell’s signs”)
Non-anatomic superficial tenderness
пЃ¬ Non-anatomic weakness or sensory loss
пЃ¬ Simulation tests with axial loading and en bloc
rotation producing pain
пЃ¬ Distraction test or flip test in which pt has no
pain with full extension of knee while seated, but
the supine SLR is markedly positive
пЃ¬ Over-reaction verbally or exaggerated body
language
пЃ¬
Waddell, et al. Spine 5(2):117-125, 1980.
Hoover Test
Helps to determine whether pt is malingering
пЃ¬ Should be performed in conjunction with SLR
пЃ¬ When pt is genuinely attempting to raise leg, he
exerts pressure on opposite calcaneus to gain
leverage
пЃ¬
Common Causes of
Low Back Pain
Muscular spasm, strain
пЃ¬ Ligament sprain
пЃ¬ Spondylosis
пЃ¬ Herniated nucleus pulposus
пЃ¬ Facet joint dysfunction
пЃ¬ Spondylo-lysis or -listhesis
пЃ¬ Seronegative spondyloarthropathies
пЃ¬
Clearing up the terms
пЃ¬
Spondylosis
– Degenerative joint disease affecting the
vertebrae and intervertebral disc
пЃ¬
Spondylolysis
– Fracture in pars interarticularis
пЃ¬
Spondylolisthesis
– Displacement of one vertebra on another
Disc rupture and herniation
Spondylo-lysis and -listhesis
Facet joint pain
Ankylosing spondylitis
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