109
K M. Iyer, Clinical Examination in Orthopedics ,
DOI 10.1007/978-0-85729-971-0_9, © Springer-Verlag London Limited 2012
T he brief functions of the lumbar spine are as follows: 1. I t transports the cauda equina to the lower limb
2. I t provides mobility to the back
3. I t provides support to the upper portion of the body and
4. I t transmits weight to the pelvis and lower limb.
I nspection
M ake sure
t hat the patient takes off all his clothes in order to thoroughly examine the lumbar spine. Take a note of the following:
T he condition of the skin, and note any abnormal skin markings – for example, any lipomata, hairy markings, cafe-au-lait spots, any birth markings, or any bony deformity. Small areas of soft mass may be en in the low back which are indica-tive of spina bifi da, or a dumbbell-shaped lipoma may be en extending into the cauda equina through a bony defect in the spine. An unusual hairy patch may be en over certain defects of the spine such as diastematomyelia, or it may be en with a lipoma referred to as a faun’s beard or a mare’s tail, which indicates some underlying bony pathology. Skin tags may be en along with certain areas of dark brown patches in neurofi bromatosis, which may impinge on the spinal cord and the spinal nerve roots. Certain birth marks or excessive port wine marks may make one suspicious of some underlying bony pathology, such as spina bifi da.
F inally examine the posture in detail. This can be analyzed as follows: With the patient standing, the shoulders should appear square and level. Any inclination or list to one side may indicate sciatic scoliosis in a prolapd intervertebral disc. Examined sideways, the lumbar spine shows a gentle lordotic curve, which may be exaggerated in a weak anterior abdominal wall. Converly an extreme sharp defor-mity or a kyphos may be en.
C hapter 9
E xamination of the Lumbar Spine
1109 Examination of the Lumbar Spine P alpation
T his is best done from behind by placing your fi ngers on top of the iliac crests and with the thumbs feeling the midline in the back, gradually proceeding upward feeling each bony prominence and each interspace. The spinous pro-cess of L4 and L5 lie above and below the interspace. Proceeding with palpat-ing upward, the spinous process of the other lumbar vertebrae can be felt. Palpation downward is done by identifying the small spinous process of S2 infe-riorly. A visible and palpable step can be felt at the lumbosacral junction indica-tive of spondylolisthesis.
P roceeding downward, the posterior aspect of the coccyx is clearly felt. This is best palpated by rectal examination, when a painful coccyx may be felt on move-ment of the mobile coccyx by bimanual examination, suggestive of coccydynia which is fairly common. The examination is completed posteriorly by palpating the posterior superior iliac crests, the greater trochanters, and the ischial tuberosities. The anterior aspect of the lumbar spine is best felt with the patient lying supine with knees bent to relax the abdominal muscles. The umbilicus lies at the level of the L34 interspace, just below which the aorta divides into the common iliac arteries. The anterior aspects of L4 and L5 are palpable below this level to the sacral promontory, which is the prominent portion anteriorly.
A fter palpating the bony prominences, the soft tissue structures are in fi ve areas:
1. M idline raphe: Palpating down the midline over the spinous process are the
supraspinous and interspinous ligaments which may be tender or a defect pal-pable between the spinous process. The paraspinal muscles are in three layers of which the superfi cial layer is easily palpable. This compris the sacrospinalis system which is made up of spinalis, longissimus, and iliocostalis. The are best palpated by asking the patient to lie prone and lift his head backward. This makes the muscles taut like a cord which may be in spasm and tender.
2. I liac crests: The are palpated throughout their entire length, and the gluteal
muscles originate from them.
3. P osterior superior iliac spines: The are points of attachment of the sacrotuber-
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ous ligaments, and the together with the sacrospinous ligaments bind the sacrum and the ischium to provide for stability of the sacroiliac joint. The sacral triangle is formed by the two posterior superior iliac spines and the top of the gluteal cleft, which may be a spot for tenderness on palpation in low back pain.
4. S ciatic area: This nerve is the largest in the body and runs downward posteriorly
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dividing into two terminal branches – namely, the tibial and peroneal divisions.
The sciatic nerve is easily palpated as it pass beneath the piriformis midway between the greater trochanter and the ischial tuberosity.
5. A nterior abdominal wall and inguinal area: The anterior abdominal muscles are
gmentally innervated from above downward just as the paraspinal muscles.
The inguinal area is examined for an abscess within the psoas muscle which can point in this area. Tenderness in this region is usually suggestive of some pathol-ogy in the hip joint.
Neurologic Examination
111 R ange of Movements
T he lumbar spine has the following movements: fl exion, extension, lateral bending, and rotation. The movements are clearly en, becau there are no restraining ribs to limit them.
1. F lexion: This is usually tested by asking the patient to bend forward with a
straight knee and touch her toes. Inability to do this is measured by the distance from the fi nger tips to the toes.
2. E xtension: This is tested by asking the patient to bend gently backward as far as
he can.
3. L ateral bending: This is not a pure movement but occurs in combination with
rotation. Ask the patient to lean to one side as far as she can, by stabilizing the iliac crest with one hand.
4. R otation: This is tested with the patient standing. The iliac crest is stabilized on
one side, while the opposite shoulder is being rotated anteriorly or posteriorly. N eurologic Examination
E ach neurologic level is tested for muscles, refl exes, and nsations which receive innervation from that level.
N eurologic Levels T12, L1, L2, and L3
T here are no individual refl exes for testing this level.
1. M uscle testing: Iliopsoas, which is innervated by T12, L1, L2, and L3.
T his is the main fl exor of the hip and is tested by asking the patient to actively rai his thigh while sitting over the edge of the table, with his pelvis stabilized.
2. S ensation testing: The nsations to the anterior aspect of the thigh between the后备人才
天猫和淘宝的区别inguinal ligament and the knee joint are mainly supplied by the nerves of L1, L2, and L3. The three dermatomes supply this area in an oblique fashion.
N eurologic Levels L2, L3, and L4
1. M uscle testing: This is mainly done by testing the quadriceps and the adductors.
T he quadriceps, which is supplied by the femoral nerve, is tested by asking the patient to extend his knee against resistance while sitting at the edge of the table and with the distal thigh stabilized. The
adductors are tested as a group by asking the patient to adduct his legs against resistance, with the patient sitting as when examining the quadriceps.
1129 Examination of the Lumbar Spine N eurologic Level L4
1. M uscle testing: The tibialis anterior, which is supplied by the deep peroneal
nerve.
T his muscle is tested by dorsifl exion and inversion which is resisted on dorsal and medial aspects of the head of the fi rst metatarsal bone.
2. R efl ex testing: Plantar refl ex
T his is a deep tendon refl ex supplied by nerves of L2, L3, and L4 – mainly by the L4.
3. S ensation testing: This involves the dermatome over the medial side of the leg.
The knee reprents the dividing line between the L3 and L4 dermatomes. In the leg, the crest of the tibia reprents the dividing line between the L4 dermatome on the medial side and the L5 dermatome on the lateral side.
N eurologic Level L5
1. M uscle testing: There are three muscles to be tested at this level. The extensor
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hallucis longus which is supplied by the deep peroneal nerve is tested by placing the thumb on the extensor aspect of the big toe. The patient then dorsifl exes it against resistance. The gluteus medius which is supplied by the superior gluteal nerve is tested by the patient abducting the limb against resistance when lying on her side. The extensor digitorum longus and brevis, which are supplied by the deep peroneal nerve are tested by resisted dorsifl exion of the patient’s toes.
2. R efl ex testing: This is tested by the tibialis posterior refl ex which is doubtful and
uncertain. This done by tapping on the medial side of the foot just before its inrtion into the navicular, holding the foot in dorsifl exion and eversion. This should elicit the plantar inversion respon.
3. S ensation: This is tested in the dermatome covering the lateral aspect of the leg
and the dorsum of the foot.
婉转和宛转的区别N eurologic Level S1
1. M uscle testing: This is tested in three muscles: The peroneus longus and brevis,
which are supplied by the superfi cial peroneal nerve and are tested by resisting eversion of the plantigrade foot. The gastrocnemius and soleus groups which are supplied by the tibial nerve are tested by the patient resisting plantarfl exion of the foot, with the knee straight and kept fl exed to 90°. The gluteus maximus which is supplied by the inferior gluteal nerve is tested with the patient lying prone with hips extended and the knees fl exed, at which point the tone of the gluteus maxi-mus is palpated.
星星竹海113Superfi cial Refl exes
2. R efl ex testing : Tendoachillis refl ex.
T his is a deep tendon refl ex which is tested with the patient lying prone. The tendon is tapped while the foot is held in dorsifl exion.
3. S ensation testing : The S1 dermatome is tested on the lateral malleolus side and the lateral side and plantar surface of the foot.
N eurologic Level S2, S3, and S4 T
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he S2, S3, and S4 nerves form the principal nerves to the bladder and the intrinsic muscles of the foot. This is best en as toe deformities, as the bladder cannot be isolated for testing.
T here is no deep refl ex supplied by S2, S3, and S4.
T he perianal nsation is arranged in three concentric rings and tested by a sharp instrument which determines the nsation supplied by S2, S3, and S4/5 der-matomes, with the S4/5 being the innermost ring of supply followed by S3 in the middle and the S2 outermost (Table 9.1).
S uperfi cial Refl exes
T here are three main superfi cial refl exes, which are tho of the upper motor neu-ron. The are mediated through the cerebral cortex or the central nervous system. The patellar tendon and Achilles tendon refl exes are of the lower motor neuron type or deep tendon refl exes requiring tendon stimulation, which are mediated through the anterior horn cell.
1. S uperfi cial abdominal refl ex : The abdominal muscles are innervated gmen-tally, the upper muscles from T7 to T10 and the lower muscles from T10 to T11. The muscles are tested by stroking a sharp hammer in each quadrant of the abdominal muscles when their respon moves th
e umbilicus toward the stroked point. This helps in localizing the level of the lesion (a lower motor lesion), by locating the quadrant where the refl ex is not en.
2. S uperfi cial cremasteric refl ex : This is elicited by stroking the inner side of the upper thigh with a sharp instrument when the scrotal sac on that side is pulled up by the contracting cremaster muscle.
3. S uperfi cial anal refl ex : This is en as a contraction of the external and anal sphincter muscles when the perianal skin is stroked. T able 9.1 N eurology of the lower extremity D isc R oot R eflex M uscles
S ensation L 3-L4 L 4 P atellar refl ex A nterior tibialis
M edial leg and Medial foot L 4-L5 L 5 N one
E xtensor hallucis longus L ateral leg and dorsum of foot L 5-S1 S 1 A chilles refl ex P eroneus longus and brevis
L ateral foot
