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Low back pain neuro exam

Low back pain neuro exam






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    Low back pain neuro exam Low back pain neuro exam Presentation Transcript

    •  The exam is where you have a chance to narrow down your differential So what is your differential for Low Back pain?
    •  Lumbar Spondylosis Lumbar Spondylolisthesis Lumbar Radiculopathy Muscle Strain Sacroiliitis Scaroiliac dysfunction Spinal Stenosis Spinal tumor Cauda Equina Glut max tendinosis Greater trochanteric bursitis Hip OA Myositis ossificans
    •  Gait: able to heel and toe walk, gait intact ROM: limited AROM of the L spine in all planes Motor: 4/5 b/l hip extension and abduction 5/5 strength in the bilateral lower extremities including HF,KE, KF,AD, EHL, PF, inversion, eversion Sensation: intact to light touch in all dermatomes tested from L2- S1 bilaterally Reflexes: 2+ b/l patella and Achilles, plantar response down going, proprioception intact Palpation: Diffusely tender over lumbar paraspinals -TTP over the b/l greater trochanters and bilateral SI joint Tone: normal in the b/l LEs Lymph: no lymphadenopathy at groin or popliteal fossa Provacative tests: - SLR, seated root (slump test), Kemp, FABER testing, FADIR testing, Elys test to 0 degrees, Obers negative bilaterally
    •  Gait Eval Look at feet, ankle, and knees Heel strike, lat foot, then cross over medially to big toe off Look at shoe wear What is trendelenberg ?
    •  Trendelenberg Marilyn Monroe Weak Glut med Hip Abductor Sup gluteal N L4/L5 S1
    •  Controversial if should do this, can worsen pain Flexion 90 degrees Extension 30 degrees Lat Bending 30 degrees
    •  Muscle Grading 5 full strength and full range 4 less than full strength, full range 3 against gravity full range 2 gravity eliminated, full range 1 twitch 0 nothing
    •  HE; one of the core muscles Range 0-30 Glut max Hamstrings How isolate hamstring? Does it matter? Glut max prime mover (inf gluteal nerve L5, S1, S2) What is the most common herniation?
    •  HF Range 0-125 Iliopsoas (iliopsoas nerve L2,L3) prime hip flexor Rectus femoris, sartorius (fem nerve L2,L3,L4)
    •  KE Range degrees Quads (Rectus femoris, vastus lateralis, vastus intermedius, vastus medialis oblique) femoral nerve L2/L3/L4
    •  KF Range 0-135 Need greater than 90 degrees to stand up out of chair Hamstrings:  Semimembranosus (sciatic, tibial portion L4/L5/S1/S2  Semitendinosus (sciatic, tibail portion L4/L5/S1/S2  Biceps Femoris(Long head (sciatic, tibial portion L5/S1/S2, SHORT head common fibular portion L4/L5/S1/S2
    •  AD Range 0-20 Tibialis anterior, deep peroneal nerve L4/L5/S1
    •  EHL does toe extension Deep fibular nerve L4/L5/S1
    •  PF Range 0-50 Muscles Gastroc/Soleus primarily S1
    •  Inversion Tibialis posterior, tibial nerve L4/L5/S1 More subtle than AD
    •  Eversion Peroneus longus and brevis, superficial fibular nerve L4/L5/S1
    •  Patient with AD weakness and HE weakness, where is the lesion?
    •  Dermatomes Useful to differential muscle weakness vs nerve involvement vs myopathy
    •  Lumbar paraspinals Consistent with muscle sprain and facet issues
    •  Greater Trochanter Bursitis versus gluteus medius tendinosis
    •  SI joint SI joint or gluts
    •  What is tone? What is spasticity?
    •  What do you rule out here? What maneuver’s can you double up on Check pop fossa during SLR Check groin during FABER
    •  SLR/Seated Root Positive from 30 to 70 degrees
    •  Kemp/facet loading
    •  FABER: Flexion/Abduction, External Rotation Opp SI joint, or hip pain
    •  Ober’s Check’s TFL tightness Press on TFL to find tender points which also signifies tightness Found a lot in runners Changes running mechanics
    •  FADIR Flexion, ADduction, Internal Rotaion
    •  ELY’S test, tests quad tightness Causes pelvic tilt Putting more stress on facets
    •  Fellows now pair up