LUMBAR SPINE EXAMINATION AND ASSESSMENT. Dermot More O Ferrall, M.D. President, Advanced Pain Management

Transcription

1 LUMBAR SPINE EXAMINATION AND ASSESSMENT Dermot More O Ferrall, M.D. President, Advanced Pain Management

2 Objectives Importance of good history Systematic approach to P/E Understand limitations Problem Focused approach Radicular Pain - Axial Pain

3 History and Examination You say it s a sharp Stabbing pain. Hmmm..

4 Axial Low Back Pain Interspinous ligament, Zygapophysial and Sacroiliac joint and Disc pain topography are similar Lewis T, Kellgren JH: Observations relating to referred pain, Clin Sci 4:47, 1939 Mooney V, Robertson J, The Facet Syndrome, Clin Orthop 115: , 1976 Fortin JD et al, Sacroiliac Joint: Pain Referral Maps Upon Applying a New Injection/Arthrography Technique. Spine 19(13): , 1994

5 Axial Low Back Pain No history or physical findings reliable predictors of source of Chronic axial low back pain Schwarzer et al. The prevalence and clinical features of IDD in patients with Chronic LBP. Spine 20: , 1995 Jackson RP et al. Facet joint injection in low back pain: A prospective statistical study. Spine 13(9):966, 1988 Dreyfuss P et al.the value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine, 21(22), , 1996 Calvillo O et al. Anatomy and pathophysiology of the SIJ. Cur. Rev. of pain 4:356-61, 2000

6 Imaging in Chronic Axial Back Pain MRI correlates poorly with source of pain Boden SD et al, JBJS,72: 403-8, 1990 Jensen M et al, N Eng J Med, 331:69-73, 1994 Boss N et al, Spine 20: , 1995 Yu SW et al. Am J Neuroradiol 10: , 1989 CT correlates poorly with source of pain Schwarzer AC et al, Spine, 20: , 1995 Weisel et al, The incidence of positive CAT scans in an asymptomatic group of patients. Spine, (9), , 1984 Rothman RH. The study of computer assisted tomography, Spine 9;548,1984 X-ray correlates poorly with source of pain Jajic I et al, Clin Rheumatol 6:39-41, 1987

7 History and Exam Excellent for diagnosing Radiculopathy and level Red flag conditions Chronic Pain Syndrome Non Spinal causes of referred pain BUT Limited in diagnosis of causes of Chronic Axial LBP

8 Pain History LOCATION Radicular Axial REFERRAL Discrete, Dermatomal - Radicular Diffuse, above knee - Axial

9 Pain History MECHANISM OF INJURY Flexion, rotation, compression Disc, Vertebral body Extension - Posterior elements Trauma, Pregnancy, Post fusion - SI Joint

10 Pain History TIMING Early AM - Inflammatory During day Mechanical Nocturnal - Malignancy QUALITY Shooting, burning, paresthesias -Neuropathic Dull, aching, cramping - Nociceptive

11 Pain History AGGRAVATING FACTORS Leg pain with ambulation - Claudication Flexion - Discogenic Extension - Posterior Elements, Foraminal stenosis

12 Pain History RELIEVING FACTORS Flexion Spinal stenosis, Posterior Element Extension Disc disease Lying Supine- IDD

13 Red Flags Night pain, Weight loss - Malignancy B/B/ Sexual function - Cauda Equina - Cord compression Fever, Chills- Infection

14 The River Liffey THE END THANK YOU

15 Physical Examination Inspection Range of Motion Palpation Flexibility Neurological Provocative tests

16 Physical Examination Lumbopelvic Rhythm Muscle Imbalance Kinetic Chain Non Organic signs Non Spinal Examination

17 Pelvic tilt Muscle Balance between back extensors/ hip flexors and the Abdominals /Hip extensors Anterior Pelvic Tilt - Increased Lumbar lordosis - tight IP, RF, Thoracolumbar fascia or weak Abdominals. Resulting lengthening/weakening of HS, Gluteals

18 Pelvic Tilt Posterior Pelvic Tilt - loss of lumbar lordosis secondary to tight HS, Gluteals and Abdominals with lengthening/weakening of the IP, RF and PS

19 Inspection Posture Kinetic Chain - Feet/ Ankles Knees/ Hips Pelvis Fortin Finger Test

20 Inspection Skin - Hairy patch, Varicella Zoster, Tags, Café au lait, Neurofibromas, etc Muscle - Atrophy, Spasm

21 Spinal Alignment Kyphosis Lumbar lordosis Scoliosis Height of Shoulders, Scapulae, Iliac Crests, Gluteal folds, Knee creases, malleoli Flat spots / straightening of spine - Segmental dysfunction

22 Inspection Gait - Normal, Heel, Toe, Tandem, Squat Gait deviations - Antalgic L3/Femoral - Knee buckling Upper lumbar radiculitis - Hip Flexion (Femoral stretch test) L4, L5/ Peroneal- Steppage, Slapping L5/Superior Gluteal - Trendelenburg

23 Range of Motion Quantity Quality Pain production

24 Lumbar Flexion Lumbar (40%) and Pelvic (60%) component Normal 80 Degrees AAOS, 1965 Finger floor Merritt JL et al, Measurement of trunk flexibility in normal subjects: reproducibility of three clinical methods, Mayo Clinic Proc, 61, , 1986 Schober Schober P, Munchn. Med. Wochenschr., 84, , 1937 Pain with disc disease Vs compression fracture

25 Lumbar Extension Normal 30 degrees AAOS, 1965 Standing Prone on elbows Greenman 1989 Prone full push-up Mc Kenzie 1981 Pain with Posterior Element dysfunction, foraminal Stenosis

26 Lumbar Lateral Flexion Normal 35 degrees AAOS, 1965 Finger Knee Posterior axillary fold in line with spinous process of S1 Pain with foraminal stenosis

27 Lumbar Rotation Normal 45 degrees AAOS, 1965 Standing with fixed pelvis Seated Quadrant Loading Pain - Posterior Element

28 Standing Palpation Surface Anatomy: Iliac crest level with L4/5 PSIS level with S2 spinous process Percussion tenderness Spinous processes, ligaments Transverse processes/ Facets Paraspinal muscles

29 Standing Palpation Iliac Crest SI Joints Greater Sciatic Notch Greater Trochanter Ischial Tuberosity Coccyx Muscles

30 Seated Examination Seated Neurological Examination Slump Test SLR

31 Neurological Exam MMT (0-5) Sensation (0-2) Reflexes (0-4) Tone UMNL, Proprioception, Coordination Radiculopathy - findings in 2 muscles with the same root but different peripheral nerves

32 Dermatomal maps

33 NEUROLOGICAL L1 L2 L3 L4 L5 S1 MMT Iliopsoas Adductors Vastus Lateralis Add. Magnus Vastus Medialis Tibialis Anterior EHL Tibialis Post Gluteus Med Peroneus Longus Gastrocnemius Gluteus Max SENS. Groin Prox. Anterior Thigh Distal Anterior Thigh Medial Calf Lateral Calf, dorsomedial foot Plantar foot. Posterior Calf REFLEX Cremasteric Cremasteric Quadriceps MSR Quadriceps MSR Medial Hamstring MSR Gastrocnemius/ soleus MSR

34 L1 MMT - Sensation - Groin Reflex - Cremasteric

35 L2 MMT Iliopsoas (Hip flexion) Sensation - Mid anterior thigh ASIA 1996 Reflex - cremasteric

36 L3 MMT - Adductors (Hip adduction) - Quadriceps (Knee extension) Sensation - distal anterior thigh Reflex - Quads MSR

37 L4 MMT Vastus medialis (knee extension), Tibialis Anterior (ankle dorsiflexion) Sensation - Medial Calf Reflex - Quadriceps MSR

38 L5 MMT - Gluteus Medius (Hip abduction), Ext. Hallucis Longus (Big toe extension) Sensation - Lateral calf and dorso- medial foot Reflex - Medial Hamstring

39 S1 MMT - Gastroc/Soleus (Plantar flexion), Peroneus longus (Eversion), Hamstrings (Knee flexion), Gluteus Maximus (hip extension) Sensation - Post calf and plantar surface of foot Reflex - Gastroc/Soleus MSR

40 Supine Examination Hip, Knee, Ankle ROM Landmarks ASIS, Symphysis Pubis Leg Lengths Abdominal Examination Pedal Pulses

41 Supine Examination Thomas Test Hip Joint ROM FABERs Hamstring Flexibility Root Tension Signs Piriformis Stretch Tests Thigh Thrust SI Joint Distraction Gaenslens

42 Side Lying Hip Abduction strength (Gluteus Med-L5) SI Joint Compression test Obers test (ITB) Trochanteric tenderness Rectal Examination - Tone, Sensation, Anal Wink, BC reflex, Coccyx, Piriformis, Masses, Prostate

43 Prone Tests Palpation Prone press-up. Symmetry of transverse process Femoral stretch test Yeomans, Sacral thrust Hip Extensor Strength

44 Non Organic signs Waddells signs - Distraction, Overreaction - Regionalization, Simulation - Tenderness Hoovers Waddell G et al, Nonorganic physical signs in LBP, Spine, 1980; 5: Kummel BM. Nonorganic signs of significance in LBP, Spine, 1996; 21: Magee DJ, Orthopedic physical assessment, WB Saunders Co, Philadelphia, 1992;

45 Blarney Castle

46 Problem Focused Examination Radiculopathy Sacroiliac Joint dysfunction Facet joint dysfunction Myofascial pain

47 Root Tension Testing SLR 90% sensitive. Supik LF, Spine, 19(9), , 1994 Crossed SLR Hudgins WR., J Occup. Med, 21(6), , 1979 Sensitivity 25%, Specificity 75% Femoral stretch test The femoral stretching test : A valuable sign in diagnosing upper lumbar disc herniations, Estridge MN, J. Neurosurg., 57, , 1982

48 Sacroiliac Joint Dysfunction Diagnosis of Sacroiliac joint pain: Validity of individual provocation tests and composites of tests Laslett M., Aprill C., et al. Manual therapy 10 (2005) patients, 6 Provocation tests SIJ compression, SIJ distraction, Thigh thrust, Sacral thrust and Gaenslens 3 0f 6 positive: Sensitivity 94%, Specificity 78% Zero of 6 positive: ruled out sacroiliac joint pain Fortin Finger Test Am J Orthop 1997;26:(7), 477

49 Facet Joint Dysfunction Literature unclear All agree on paraspinal tenderness Only 2 studies utilizing comparative anesthetic blocks Schwarzer et al, Spine 1994,19; Laslett et al, Spine J, 2006(6) Both found Extension and rotation 100% sensitive but not very specific. Not midline pain

50 Facet Joint Dysfunction Helbig et al, Spine Extension and rotation No pain below the knee Back with thigh or groin Jackson et al, Spine 1988; 23: patients, 127 variables but found none Cohen S et al, Anesthesiology, 2007,106; Paraspinal tenderness only Facet loading correlated with failure of RF Revel et al, Spine 1998; 23: Not worsened by extension and rotation

51 Facet Joint Dysfunction Facet Joint/ Paraspinal tenderness Axial pain worse with extension? Pain reproduction with extension and ipsilateral rotation (Quadrant or Facet Loading)? Biomechanically: Increased risk with increased Lumbar lordosis

52 Myofascial pain Myofascial trigger points Palpable taut band in a muscle Pain reproduction with compression of taut band Pain with stretching and resisted activation of the symptomatic muscle

53 Non Spinal Examination

54

55

56

57 THANK YOU THE END

58 Flexibility Iliopsoas - Thomas test Rectus Femoris - Thomas test, Ely test Hip flexor tightness associated with LBP in school aged children. Kujala UM et al, Med Sci Sport. Exerc., 24(6), , 1992 Hamstring - SLR, Popliteal Angle HS tightness strongly correlates with h/o LBP. Esola M et al, Spine 21(1), 71-78, 1996 Modified Thomas - Adductors, TFL, RF Obers Iliotibial Band

59 Facet Joint Exam Jackson RP., et al, Spine 1988; 13(9): Prospective study. 390 patients. 127 variables Unable to identify predictors of response to facet joint injection More likely to have: Older age, axial (no leg) pain, Maximal pain on extension following flexion, Pain with lumbar extension and rotation

60 SI Provocative Manoeuvers Patrick s / FABER Beetham W et al, Physical examination of the joints, WB Saunders Co. Philadelphia, PA, 1965, 139. Thigh Thrust Gaenslens Magee DJ. Orthopedic physical assessment, WB Saunders, Philadelphia, PA. 1992, SI Distraction, Compression Yeomans Sacral Thrust, Sacroiliac Joint Shear Laslett M, Williams M. The reliability of selected pain provocation tests for SI pathology. 19,(1994); Diagnosis of Sacroiliac joint pain: Validity of individual provocation tests and composites of tests Laslett M., Aprill C., et al. Manual therapy 10 (2005)

61 Thigh Thrust

62 Sacroiliac Joint distraction

63 Sacroiliac Joint compression

64 Sacral Thrust