Examination of the ThoracoLumbar Spine

Summary

Clues

• walking / mobility aids
• external appliances
• lumbar brace
• AFO

Look

Standing

• Front
  • General Manifestations of systemic disease
    • Body habitus
    • Syndromes (Marfan’s, NF)
    • pectus excavatum/carinatum (Marfan’s)
    • Skin
    • Face
  • Wasting
    • quadriceps
• Side
  • Lordosis
    • Normal 60°
      • (Hyperlordosis / swayback )
        • usually flexible def
        • associated with FFD hips
      • look for ­ prominence of buttocks
      • Reversible
        • associated. pain & muscle spasm
        • spondylolysis, ank.spond
      • Lumbar Flatback syndrome
        • rigid lumbar spine & no lordosis
        • Compression anterior wedge fractures, degeneration
  • Gibbus
    • sharp, angular kyphotic deformity. TB, tumours, other infections, fractures
  • Kyphosis / Lordosis (↑ or flat back)
• Back
  • Skin
    • Scars, sinuses
    • Cutaneous manifestations of Spina Bifida
      • Hairy patch, naevi, café-au-lait, lipomas
  • Spinal coronal alignment
    • Normal
    • Scoliosis
      • Helical abnormality
        • Structural or secondary
        • Balanced?
        • Flexible
    • List
      • abrupt planar shift of spine above certain point (pain, herniated disc, muscle spasm)
  • Symmetry
    • Shoulders
    • Scapular
    • Pelvis
    • Legs
      • Wasting
        • Buttocks, thighs, calves
    • Symmetry of stance

Feel

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Spinous processes

• tenderness, steps
• Step off deformity
  • Spondylolisthesis
    • Especially L5 S1
    • (50% step before step off is positive)
• Gibbus
  • sharp, angular kyphotic deformity

Paravertebral muscle spasm

• Trigger points
  • tender nodules within paraspinous muscles. Reaction to painful stimulus or fibromyalgia

Landmarks

• iliac crest- L4/L5 interspace
• Pelvic obliquity

Move

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LLD & block

Trendelenburg

Differentiates

• Pin
• L5 root lesion vs sciatic nerve lesion

Forward Flexion (80-90˚)

Standing with feet together & knees straight

• fingertips from floor

Comment on

• 1. Irritability
• 2. Amount (fingertips in relation to front of legs)
• 3. Spinal excursion – Modified Schrober’s test
  • (S1 – L5) 10cm above + 5cm below lumbosacral junction
  • Distance should ↑ 6cm
  • Abn: Ankylosing Spondylitis
• 4. Unrolling of the lumbar spine
  • look for normal flattening of lumbar lordosis
  • There is normal thoracolumbar movement
  • Lost in ank spond
  • limited in disc herniation
• 5. Thomas Forward Bending Test
  • Rib hump

Extension 20°

from flexed position

• if not full, perform Wall Test

Comment on

• irritable
• difficulty (hands on thighs)
• “There is a normal extension range”
  • extension narrows canal
    • spinal stenosis
    • post traumatic deformities
    • tumours
    • painful posterior elements

Lateral flexion 20°

Lateral Bending (stabilize pelvis)

normal 20-30º

look for

• asymmetry
• irritability
  • herniated sacs avoid bending to effected side

Thoracic Rotation

Walking

Walking

ck-heading">Normal Gait

• Walk away from you
• Walk towards you
• Look for
  • Antalgic
  • Sciatic gait
    • hip extended & knee flexed to reduce tension
• Ask Patient to Heel & Toe Walk
  • Heel Walk
    • L4
      • ankle dorsiflexors, L4 Tib anterior (L34 disc)
  • Toe Walk
    • S1
      • Gastrocsoleus (L5S1 disc)

Others

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• Squatting
  • proximal power
• Romberg’s if unsteady

Sitting

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• Does Deformity correct?
• Palpate

Supine

Supine

-heading">Hip ROM

• flex hip to 90° & rotate hip
• comment
• painless range of hip movement

Neurological Examination

Summary

Nerve Root	Sensation	Muscular	Reflex
L1	~ Inguinal ligament	~ Iliospoas (seated hip flexion)
L2	~ Mid AM thigh	~ Iliospoas
L3	~ SM patella	~ Quad
L4	~ MM ~ Medial lower leg & ankle	~ Tib ant	Patella
L5	~ 1st web space ~ Lat & AL leg dorsum foot	~ EHL ~ EDL ~ glut med
S1	~ PL Heel ~ Post calf ~ plantar foot	~ Gastroc, peronei, glut max	Achilles
S2	~ Pop fossa ~ Post thigh	~ Rectal Exam
S345	~ Perianal area	~ Rectal Exam – anal tone

Stretch Tests

• 1. Straight Leg Raising Test
  • Norm 70-90º
  • SLR stretches L5 & S1 by 2-6mm. – thus positive suggests lesion at L5 S1
• 2. Lasegue’sTest
  • SLR, stop, dorsiflex foot
  • Positive with radicular pain worsened
• 3. Bowstring Sign (McNab)
  • SLR, stop, flex knee to 90º, which relieves patients symptoms
  • Apply digital pressure over Popliteal fossa
  • Positive if reproduces pain
• 4. Crossed Straight Leg Raising Test
  • Extremely sensitive & specific 97%

Tone

• Tone
• Clonus
  • > 3 beats
• Fasciculations
  • Suggestive of LMN lesions

Power

• Grade Power MRC
• Palpate contraction

NOTE: L5 nerve root exits at L5S1 neuroforamen but in disk herniation it usually effects S1

• put joint into desired position
• palpate muscle
• ask patient to maintain position against you

Joint	Movement	Nerve root	Action
Hip	flexors	L2	iliospoas
	adduction	L2,3	squeeze knees together
	abduction	L4,5,1	push legs apart
	flexion	L2,3	pull knee to chest
	extension	L4,5	push knee away
Knee	flexion	L5,S1	pull heel to bottom
	extension	L3,4	hold knee straight (quadriceps)
Ankle	dorsiflexion	L4, 5	pull foot up
	plantarfiexion	SI,2	push foot down
	inversion	L4	hold foot in
	eversion	L5,SI	hold foot out
Hallux	dorsiflexion	L5	pull big toe up
	plantarfiexion	SI 2	push big toe down

• If L5 weakness test glutei to see if peripheral nerve or L5 root
• FHL same roots as ankle dorsiflexion except more sensitive at detecting weakness than the powerful ankle dorsiflexors

Sensory

• light touch
• pinprick, ice, proprioception, vibration if abnormal

Nerve Root	Area	Nerve
L2	Anterolateral thigh	LFC
	Anterior thigh	IFC
	Medial thigh	MFC, obturator
L3	Knee	infrapatellar
L4	Medial calf	saphenous
L5	Lateral calf	LCNC, SPN
	1st web space	deep peroneal
S1	Lateral foot + sole	sural
	med + lateral plantar	medial calcaneal
S2	Posterior midline calf + thigh	sural, PFC
S3, S4, S5	Rings around buttock

Reflexes

• Knee – L3, L4
• Ankle – S1
  • If Achilles reflex difficult
    • get patient to kneel on bed with feet hanging off, then re-examine
  • Reinforcement technique
    • if reflex absent ask patient to hook fingers together & pull
• Abdominal Reflexes
  • screens for thoracic spinal cord compression (Scoliosis)
  • stroked in radial manner out from umbilicus at 2/4/8/10 o’clock positions
  • muscles should contract, umbilicus moves in direction stroked
  • if no movement, indicates compression at that level
• Cremaster Reflex (L1-2)
  • stroking the inner part of the thigh normally causes contraction of the cremaster muscle causing the testes to raise on that side
• Anal Reflex (S2,S3,S4)
  • scratching the perianal skin causes contraction of the external sphincter. Absent in lesions of the lower segments of the cauda. (NOTE if there is sparing of these lowest sacral segments with the upper ones being affected, it is consistent with central cord lesion)
• Bulbocavernosus Reflex
  • first sign that spinal shock is over

Side

• Femoral Nerve Stretch Test
  • Assesses L234
  • Patient lateral, knee flexed 90º
  • Passively extend hip (hand under knee)
  • Positive if reproduces leg pain in distribution of femoral nerve
• Gluteus Medius Test

Other

• Vascular (abdomen for AAA + ovarian mass) + peripheral pulses
• Hip examination

Special Tests

Special Testsonorganic Signs of Waddel Spine 1980
• Non-anatomic tenderness
  • excessive response to minimal touch (pinching)
• Overreaction
• Distraction Sign
  • Variation between sitting + supine SLR
• Regional sensory or motor disturbance
  • Glove & Stocking
• Simulation Sign
  • Rotation pain. Or pain after axial compression elsewhere than neck & shoulders
• 3/5 is indicative of poor outcome for spine surgery
• Spondylolysis
  • Single Leg Hyperextension Test
    • Patient standing with one leg infront of other
    • Patient then leans back as far as possible
    • Support patient from behind so patient does not topple over
    • Then repeat with other leg forward
    • In unilateral spondylolysis, pain will be worse with leg extended posteriorly
• Tests to ↑ intrathecal pressure
  • Valsalva’s Maneuver
    • patient bears down as if attempting to have bowel movement
    • if pain in back or legs produced there is probable pathology either causing intrathecal pressure or involving the theca itself
  • Milgram Test
    • Patient supine, lift both legs straight 2 above table + hold position for as long as possible- if patient can hold position for 30 sec intrathecal pathology can be ruled out
• Tests for SI joint
  • Pelvic rock test
    • Compress pelvis to midline- +ve if pain in SI joint
  • Gaenslens sign
    • Supine, patient draws both knees up to chest, then shift patient to side of couch so one buttock extends over edge. Allow unsupported leg to drop over edge while opposite leg remains drawn up to chest- +ve if pain in SI joint
  • Faber test
    • (Flexion, abduction external rotation)
    • supine, place foot of involved side on opposite knee ( fig 4 position). To stress SI joint press down on knee with one hand & press down on opposite ASIS with the other hand
• Wall Test
  • Anklyosing Spondylitis
    • Stand with back to wall
    • Heels, buttocks & occiput should touch wall
• Chest expansion
  • Measure inspiratory & expiratory difference
  • should be > 5 cm
• Kyphosis
  • forward bending test
  • observe from side
  • correction test
  • hyperextension while prone
• Leg length correction
  • blocks & reassess curve
  • sitting – reassess curve
• Tripod sign for tight hamstrings
  • patient sits, knees flexed to 90°. The examiner then passively extends the knee fully. If the hamstring is tight then there will be passive extension of the hip that causes the patient to lean backwards, such that the patient needs to support themselves with their hand behind their back. (Differential Diagnosis sciatica)
• Slump
  • Variation of SLR & Lasegue in seated position
  • Patient seats on sit of table with back straight
  • Ask patient to slump – allowing thoracic & lumber spines to collapse whilst keeping head straight
  • Fully flex cervical spine
  • Then extend one knee
  • Then dosiflex foot
  • Repeat with other side

Common Physical Findings

Common Physical Findings-stripes">

Condition	Physical Findings
Herniated Lumbar Disk	~ Nerve tension tests ~ SLR ~ Lasegue’s test ~ Bowstring ~ Cross Leg test ~ Slump test ~ Sciatic notch tenderness ~ Lumbar muscle spasm ~ List away from affected nerve root ~ Neuro deficit in affected nerve ~ Valsalva maneuver
Spinal Stenosis	~ Loss of normal lumbar lordosis ~ Passive spine extension reproduces leg symptoms ~ Sciatic notch tenderness ~ Neuro deficit ~ Abnormal SLR (infrequent)
Spondylolysis	~ Lumbar tenderness at level of involvement ~ ↓ lumbar lordosis ~ Hamstring tightness with SLR ~ Pain exacerbated by hyperextension of lumbar spine ~ Passive extension ~ Active extension ~ Single leg extension test ~ Signs of associated Spondylolisthesis
Spondylolithesis	~ Signs of spondylolysis ~ Palpable step off (in severe cases) ~ Sciatic notch ~ Neuro deficit
Lumbar fracture	~ Tenderness ~ Localized swelling & haematoma ~ Lower motor neuro deficit when damage to cauda quina or nerve roots ~ Upper motor neuro if lesion above level of cauda equine
Lumbar Spondylosis	~ ↓ range of motion ~ pain exacerbated by motion (variable) ~ Tenderness
Low back strain	~ Paraspinous muscle tenderness & spasm ~ Symptoms exacerbated by forward flexion ~ List (variable) ~ Normal neuro exam