Evaluation of Lumbar Spine Disease starts with understanding the clinical back grounds. It starts with good history and physical examination. This is a teaching lecture given twice by Prof. Dr. Mohamed Mohi Eldin, professor of neurosurgery, in the Basic Spine Course, Egyptian Medical Syndicate, Cairo, March 2009 and in 2010.

1. BBaassiicc IInnttrroodduuccttiioonn iinn SSppiinnee
((UUnnddeerrssttaannddiinngg SSppiinnee PPrroobblleemmss))
DDrr.. MMoohhaammeedd MMoohhii EEllddiinn ,, MB-BCH , M.Sc., MD
PPrrooff.. ooff NNeeuurroossuurrggeerryy,,
FFaaccuullttyy ooff MMeeddiicciinnee,,
CCaaiirroo UUnniivveerrssiittyy
CCoonnssuullttaanntt NNeeuurroossuurrggeeoonn
Basic Spine Course 3/18/2009

5. Low back pain
15%
85%
no specific
specific pathology
pathology NSLBP
(mechanical)

6. “Mechanical” NSLBP
• pain is worsened with movement
• pain is improved with rest

7. Triage
• Is the LBP due to serious pathology?
• Duration of the LBP?
• What treatment is indicated for the LBP?

8. Hypotheses generated about:
• diagnosis
• physical examination
• treatment
• prevention
• contra-indications/precautions

9. Need knowledge about:
• causes of LBP
• pathology
• tests (odds ratio, sensitivity and
specificity)
• treatment effects and efficacy

10. Serious spinal pathology
• Cancer
• Infection eg osteomyelitis
• Cauda equina syndrome
• Cord compression
• Fracture (osteoporotic)
• Inflammatory diseases/arthritides
• Abdominal or cardio-thoracic pathology

11. Eliminate serious pathology
(red flags)
• unexplained weight loss
• night pain
• poor general health/systemic symptoms
• fever
• previous history of cancer
• failure to improve with bed rest & therapy
• history of trauma
• steroid use (osteoporosis)
• very severe pain/muscle spasm
• Pain that worsens in supine
• bowel/bladder frequency (cauda equina syndrome)
• widespread neurological symptoms
• non-mechanical behaviour of symptoms
• Age > 50 years
• Constant progressive non-mechanical pain
• Persisting severe restriction of lumbar flexion

13. Typical Non-typical
Presentation Presentation
Kathryn Refshauge 13

14. Decisions
• If suspect pathology, refer patient to appropriate
health professional
• If NSLBP, use knowledge (evidence-based practice)
seriousnesss
probability

15. Yellow flags
• Previous history of LBP
• Radiating leg pain, NR involvement
• Poor fitness
• Poor extensor endurance
• Poor general health
• Psychological distress (fear avoidance behaviour,
depressed)
• Much time lost from work
• Disproportionate illness behaviour
• Low job satisfaction
• Personal problems (alcohol, marital, financial)
• Adversarial medico-legal proceedings

16. Clinical Course
acute sub-acute chronic
6 weeks 3 months
Time
acute sub-acute chronic
most recover
without
intervention
some recover very few
recover
psychosocial domain
fear of activity
acute sub-acute chronic
Rx:
spinal manual
therapy
McKenzie exercises
spinal manual
therapy
exercises
exercise
cognitive
behavioural
therapy

17. Clinical Examination
· observation
· active movements
· tension tests ***
· palpation
As applicable:
· stress active movements
· neurological examination
· muscle performance
· passive tests

18. Biering-Sorensen test

19. multifidus

20. LLuummbbaarr SSppiinnee DDiisseeaassee
• Low back pain is second
to upper respiratory
problems as a reason for
visits to a physician
• In the U.S., back pain is
the most common cause
of activity limitation in
people younger than 45
years
• Cost of low back pain to
industry estimated $35-
75 billion

21. EEvvaalluuaattiioonn ooff LLuummbbaarr SSppiinnee DDiisseeaassee
• Where to start?
• What do we know?
• What to do?
• Who to consult?
• What will they do?

22. What we know v. wwhhaatt wwee tthhiinnkk wwee kknnooww**
% answering % very
Topic ?s correctly confident
SI joint pain 4.4 32.2
Lumbar stenosis 12.6 28.6
Leg length differences 42.0 27.0
Fibromyalgia 57.1 35.5
Myofascial pain (piri) 68.7 8.5
*J Am Geriatr Soc 54:1772-1777; 2006

23. EEvvaalluuaattiioonn ooff LLuummbbaarr SSppiinnee DDiisseeaassee
From the top
• Patient History:
– Location of pain
– Duration of pain
– Character/quality of
pain
– Weakness
– Numbness

24. Evaluation ooff LLuummbbaarr SSppiinnee DDiisseeaassee
• Bowel, bladder or sexual
dysfunction
• Prior or current treatments
including medication
• Smoking (smokers complain of
more severe symptoms and
have less improvement
postsurgically)
• Obesity (obese patients more
likely to suffer radicular pain
or neurologic symptoms and
carry more comorbidities)
• Diabetes (may need
neurophysiology testing)
• Psychological factors: anxiety,
depression, somatization
symptoms, stressful
responsibilities, job
dissatisfaction, mental stress
at work, negative body image,
weakness in ego functioning
(prospective predictors of
developing back pain)
• Activities that affect pain (e.g.
leaning forward in spinal
stenosis, sitting down,
coughing, sneezing, Valsalva
for herniated discs)

25. Evaluation ooff LLuummbbaarr SSppiinnee DDiisseeaassee
• Physical Exam:
– Strength
– Sensation
– Reflexes
– Range of Motion
– Palpation

26. Evaluation ooff LLuummbbaarr SSppiinnee DDiisseeaassee
• Strength exam:
– L3 - iliopsoas muscle (hip
flexion), adductor longus
(hip adduction)
– L4 - quadriceps femoris
(knee extension), tibialis
anterior (dorsiflexion and
inversion)
• L5 - gluteus medius/minimus
(thigh abduction and medial
rotation), extensor hallicus
longus (big toe extension),
peroneus longus and brevis
(plantar flexion and eversion)
• S1 - gluteus maximus (thigh
abduction), biceps femoris (hip
extension), gastrocnemius
(plantar flexion)

27. Evaluation ooff LLuummbbaarr SSppiinnee DDiisseeaassee
LLoowweerr eexxttrreemmiittyy sseennssaattiioonn

28. EEvvaalluuaattiioonn ooff LLuummbbaarr SSppiinnee DDiisseeaassee
• Reflexes:
– L3 - iliopsoas reflex
(meaningful?)
– L4 - knee jerk
– L5 - extensor hallicus reflex
(meaningful?)
– S1 - ankle jerk
– Babinski - in adults, UMN
lesion from motor strip to
lower spinal cord

29. EEvvaalluuaattiioonn ooff LLuummbbaarr SSppiinnee DDiisseeaassee
• Range of Motion:
– Straight leg raise - most
sensitive for sciatic pain
syndromes
– Pain in contralateral leg with
straight leg raise is most
specific for sciatic pain
syndromes
– Lumbar flexion/extension
(lumbar stenosis worse with
extension, better with
flexion)

30. EEvvaalluuaattiioonn ooff LLuummbbaarr SSppiinnee DDiisseeaassee
• ROM to rule out other
causes of back/leg pain:
internal and external hip
rotation
• Palpation over spine, SI
joint, pelvis and hip

31. Evaluation ooff LLuummbbaarr SSppiinnee DDiisseeaassee
• Clinical impression:
– lumbar disc herniation: pain, paresthesias, weakness,
depressed DTRs in an anatomic distribution (i.e. down
lower extremity)
– lumbar stenosis: diagnosis made mainly by history; low
back/leg pain with walking or standing improved by
sitting or lying down (not just standing still); no severe
cramping in calf; no trophic changes in skin; a.k.a.
neurogenic claudication

32. Evaluation ooff LLuummbbaarr SSppiinnee DDiisseeaassee
• Clinical impression:
– lumbar instability: pain with motion; improved with lying down;
>5 mm motion on flexion/extension x-rays indicates unstable
motion segment; look for defects in neural arch (lamina, pedicle,
pars interarticularis); 30% of patients with degenerative
spondylolisthesis (subluxation) will have progressive slippage
– compression fracture: acute to subacute onset of pain, pain to
palpation; +/- history of trauma/cancer
– musculoskeletal: pain with active but not passive motion; point
tenderness over joint; +/- history of trauma

33. Evaluation ooff LLuummbbaarr SSppiinnee DDiisseeaassee
• If clinical suspicion high for ‘soft tissue’ (i.e. muscle, tendon, joint,
ligament) source of symptoms then: NSAIDS, narcotics,
antidepressant, cox-2 inhibitor, PT (exercise), +/- muscle relaxants,
+/- chiropractor referral, +/- acupuncture, +/- behavioral therapy, ?
corsets, ?massage, ?traction, ?TENS, ?epidural/facet injections,
BUT…continue ordinary activities in the acute period* AND in the
post-acute period begin conditioning activities to strengthen back,
legs, abdomen to prevent recurrence^
• +/- = some evidence; ? = unknown
• *NEJM 332:351-5, 1995
• ^JAMA 272:1286-91, 1994

34. Evaluation ooff LLuummbbaarr SSppiinnee DDiisseeaassee
• Options when clinical suspicion low or diagnosis unclear:
– 1. Observe (80-90% will resolve in <6 weeks)
• most common diagnosis of acute (i.e. <6 weeks) back pain =
“lumbar strain”
• pathobiology ( any pain sensitive structure): muscle, tendon,
ligaments, disc, facet joints, periosteum, meninges, blood
vessels, or ‘degenerative changes*’
• NSAIDS, narcotics, antidepressant, cox-2 inhibitor, PT while
you are observing
– 2. Imaging
• BUT ASK THE PATIENT: are you willing to have surgery or other
invasive procedure if we do this work up?
• For back pain pts: 4% will have compression fx, 1% will have a
tumor, 3% will have a herniated disc

35. Imaging ooff LLuummbbaarr SSppiinnee DDiisseeaassee
• If clinical suspicion high for intraspinal source of
symptoms – i.e. radiculopathy, neurogenic
claudication, lumbar instability, compression fx
then:
– 1) MRI, MRI, MRI unless there is a
contraindication (see next slide)
• Add contrast only if patient has had prior surgery or a
history of cancer; perhaps with a demyelinating process like
multiple sclerosis
• If not sure; order without contrast and radiology will pick up
the ones that do need it

36. Imaging ooff LLuummbbaarr SSppiinnee DDiisseeaassee
– 2) If there is a contraindication to MRI then CT
myelogram (contraindications to MRI = heart stent < 2
weeks old, defibrillator, pacemaker, pain pump, spinal
cord or deep brain stimulator, prior lumbar spine
instrumentation, programmable shunt)
• Questions?: call radiology or specialist involved in placing device
or hardware
• If patient is too large for closed MRI then order open MRI
• CT is WAY OVERUTILIZED as a spine diagnostic test and delivers A
LOT of radiation to the patient

37. Imaging ooff LLuummbbaarr SSppiinnee DDiisseeaassee
– 3) if signs of spondylolisthesis then
flexion/extension x-rays (lateral)
– 4) pain medications (NSAIDS, narcotics, +/- oral
steroid taper, +/- muscle relaxant)
– 5) Consultation after MRI or CT myelogram
results show something other than ‘degenerative
changes’*

38. Consultation aatt tthhee SSppiinnee CCeenntteerr
• ‘Who’ should I send ‘what’ to?
• General recommendations:
– Acute pain problems – surgeons & pain management
• Surgeons – usually after imaging
– Active smokers will be strongly encouraged to stop
– Poorly controlled diabetics (Hgb A1C > 7) will result in re-evaluation
request with primary care prior to surgery
• Pain management – does not require imaging
– Chronic pain problems – physiatry & neurology
• Does not require imaging

39. SSPPOORRTT SSttuuddyy**
• Conservative therapy isn’t the worst idea for patients with a
herniated disc and mild to moderate symptoms
• 2-year prospective randomized trial of patients with
radicular symptoms > 6 weeks and imaging evidence of a
herniated disc
– Randomized to surgery or PT, exercise, NSAIDS
• LOTS of patients cross-over to opposite group if symptoms
are too mild or too severe
• BUT at 2-year follow-up, both surgery and conservative
management was effective
• *JAMA 2006;296:2451-2459

40. SShhoouulldd II rreeiimmaaggee??
• Have symptoms or signs changed
significantly?
• Has there been a recent intervention (e.g.
surgery) or trauma?
• Look at patient’s chart – has it been >1 year
since last imaging?
• If the answer to these 3 questions is “no”
then reimaging is not indicated

41. SSuummmmaarryy
• Start with good history and physical
• Is this emergent, urgent or routine?
• Is the cause most likely disc, stenosis,
instability, compression fracture or soft
tissue?
• Typically start conservative and escalate as
necessary

42. CClliinniiccaall HHiissttoorryy and Physical
Examination on Spine Injury
(Part I)

43. The Importance of History and
Physical Examination
• The most valuable service
the correct diagnosis
the magnitude of the problem
the appropriate treatment

44. Image studies
• Image studies Vs.
Time-consuming process of history taking and P.E.
• High false positive rate for spinal disease
• No information about the source of pain
• To confirm the diagnosis
• To help guide any surgical procedure

45. History
• Structural spine: vertebrae, joints
 Symptoms: axial
• Neurologic spine: cord, cauda equina, nerve root
 Symptoms: peripheral, radicular

46. History
• Backache
 In the lumbosacral junction?
 In the thoracolumbar junction?
 In the buttock and thigh?
• Sciatica?

47. History
• The ratio of back pain to leg pain symptoms
• The pain intensity on a scale 1 to 10
• Functional impairment:
 Stable
 Deterioration
• Psychosocial issues

48. Axial Symptoms: Back and Neck Pain
• To characterize the nature of the pain
 Location
 Onset
 Duration
 Character
 Periodicity
 The precipitating factors
 The aggravating factors
 The relieving factors

49. Location
• Local or diffuse, midline or paraspinous
• Midline pain:
spondylolisthesis or bony pathology
• Paraspinous pain:
muscular and spasm
• Focal, highly localized pain:
fracture, tumor, infection or single-level arthrosis or
instability
• Diffuse symptoms: DDD
• Chronic, diffuse symptoms are seldom likely to warrant
surgical treatment

50. Onset
• Acute onset:
acute injury
• Insidious onset:
repetitive trauma, degenerative disease or a
progressive disorder
• Insidiously but progressive rapidly:
more serious underlying causes
 Pathological fracture: tumor, infection, or osteoporosis,
 Visceral disease: pancreatitis, AAA

51. Duration
• Sprain/strain causing backache usually
improves within 6 to 8 weeks of onset
• Degenerative disease pain waxes and wanes
over a period of years or decades
• New pains, or pains that are new to
longstanding backache

52. Character
• Most backache: fairly focal pain
intensified by activity and fatigue,
improved by rest
• Neoplasm/infection: boring, deep pain
unrelieved by rest or recumbency
• Instability: sharp, stabbing, incapacitating pain
superimposed on a baseline ache
a shift or “catch” with motion

53. Character
• Discogenic pain:
intensified by sitting and vibration exposure,
flexion/extension, and axial loading
• Discitis, osteomyelitis
greater intensity, absolute intolerance of motion

54. Periodicity
• Symptoms recur more frequently
• To miss work several times in a given year
Need further evaluation and more aggressive treatment

55. Factors that
Precipitate, Aggravate, Relieve pain
• Flexion: aggravate disc-related symptoms
• Extension: irritate the facets
• Motion: trigger instability, causing acute giving out or
stabbing pain.
• Whole body vibration: precipitate neuropeptide
release that can sensitize nerve endings and directly irritate
the disc

56. Factors that
Precipitate, Aggravate, Relieve pain
• Mechanical disorder:
Pain caused by bending, lifting, twisting, or axial loading, and
relieved by recumbancy
• Discogenic pain:
Pain aggravated by flexion, or by prolonged sitting or riding in
a car
 Back pain caused by hypertension may be facet-related
 Leg pain in extension usually is a result of spinal stenosis

57. Factors that
Precipitate, Aggravate, Relieve pain
• Profound morning stiffness:
requiring 30 mins to an hour to “loosen up” (inflammatory
arthropathy)
• Inquires about injury and the circumstances
associated with the pain first appearing
• Did pain come on immediately after an accident?
• Was there an examination or radiography at that time?

58. Peripheral Symptoms: Arm and Leg Pain
• Radiculopathy:
Painful, hyperesthetic, numb, tingling, burning
• HIVD Vs. Central spinal stenosis
• Thoracic spine disorder: Belt-like radicular symptoms
Herpes zoster; the pain is severe and predates the vesicles

59. Peripheral Symptoms: Arm and Leg Pain
• Neurogenic Vs. Vascular claudication
(The spine in flexion or extension)
 Walk
 Stand still
 Sit
 Uphill
 Downhill
 Pedaling a bicycle
 Lean forward over a shopping cart (on a counter)

60. Peripheral Symptoms: Arm and Leg Pain
• Radicular pain reproduced by coughing,
sneezing, or straining at stool (increasing
intrathecal pressure)
• Lhermitte’s sign
• Resting the forearm over the head

61. Peripheral Symptoms: Arm and Leg Pain
• Loss of bowel continence, urinary retention,
and saddle anesthesia (accompanied by
varying degrees of leg weakness)
---Cauda Equina Syndrome
• Spasticity, and urinary incontinence (diffuse
lower and upper extremity weakness)
---Spinal Cord Injury

62. Clinical History and Physical
Examination on Spine Injury
(Part II)

65. Lumbar Spine Assessment

66. Low Back Pain (LBP)
• 90% of all Americans
• Minor insultsmajor injuries
• Maintain normal lordotic and kyphotic curves
to avoid injury

67. Clinical Anatomy
• 5 vertebrae=lumbar spine
• P.320, fig. 10-2
– Facets
– Processes
– Foramen
– “Scotty Dog”

68. Evaluation
• Primary role of ATC:
– On-field evaluation:
• Rule out (R/O) bony trauma which has, or may, damage
to spinal cord
– Clinical evaluation:
• Evaluate specific cause of injury and devise a
rehabilitation plan

69. History
• Location of pain:
– Localized or radiating?
• Onset of pain:
– Acute, chronic, insidious?
• Consistency of pain:
– Constant/intermittent?
– Improves/Worsens with
activity?
• Mechanism:
– Flex, ext, rotation, lat. Flex
– Direct blow/trauma

70. History
• PMH of injuries/surgery?
• Smoker?
• Bowel/bladder
symptoms?
– Incontinence or Ý
frequency
– Immediate referral
• Referral history
– Time in the medical
system?
– # of physicians seen?

71. Inspection/Observation
• Sagittal curvature
• Scoliosis
• Frontal curvature
• Normal curves
• Standing posture
• Shoulders
• Head
• Walking posture (gait)

72. Observation/ Inspection
• Paravertebral muscles
• Symmetry / spasm
• PSIS level
• Overall attitude

73. Palpation
• Transverse processes
• Spinous processes
• PSIS
• Paravertebral
musculature
– Symmetry
– spasm

74. Functional testing
• Gross ROM assessment
only
• Trunk Extension = 45º
– Lordosis should increase
• Trunk Flexion = 9045º
– Lordosis should decrease
• Rotation
• Lateral flexion
• Symmetry >
Goniometry

75. Pathologies/Injuries
• Muscle strains—p.353
• Facet joint syndrome-p.
353
• Disk lesion—p. 354
• Spondylopathies—
p.292

76. Muscle Strains
• Pain localized to
paraspinal musculature
& PSIS
• Spasm probable
• Limited flex. & ext.
(pain)
• No radiating pain
• May not correlate to
specific mechanism

77. Facet Joint Syndrome
• Table 10-10,p.354
• ~40% of all LBP
• Vague symptoms that
mimic other pathologies
• Common with repeated
spine-loading activities
• Localized pain
• Often improves with activity
• Nerve entrapment may
result from compensatory
posturing
• Worsened by:
– Repeated spine-loading
activities (ext, side
bending, rotation)
– Poor LE flexibility
– Poor Trunk strength

78. Disk lesion
• Crack in annulus fibrosus
herniation of nucleus
pulposus
• Pressure on nerve
rootpain/burning
sensation
• “Bulge” ¹ pathology
• Radiating pain into
buttocks and down leg
• MRI for best diagnosis
• Altered standing posture
• Symptoms Ý with activity
• Bilateral or unilateral
symptoms
• Usually acute onset

79. Spondylopathies
• Vertebral defect
• May occur at any
age/sports
• Congenital?
• Stress fx?
• Common is sports with
forced hyperextension
• Generally occurs at L4-
L5 or L5-S1 levels

80. Spondylolysis
• Defect at pars
interarticularis
• Unilateral or bilateral
• Signs/ Symptoms:
– NL spinal alignment
– LBP Ý during & after activity
– Localized lumbar spine pain
– NL flex; restricted ext.
– (-) neuro. Test
• X-rays show “collared”
Scotty Dog

81. Spondylolysthesis
• May occur with
spondylolysis
• Anterior displacement
of proximal vertebrae
on distal
• Pain more
intense/constant than
spondylolysis
• Neuro signs sometimes
(+) if displacement
worsens
• Possible step-off deformity
• X-rays show “decapitated”
Scotty Dog
• (+) Stork test

82. Straight leg raise test (SLR)—
p.347, fig. Box 10-9
• Supine with knees extended
• PROM hip flexion to point of
discomfort or end of range
• ß hip flexion and move into
passive dorsiflexion
• (+) = pain reproduced and
recurs with reduced SLR
• (-) =pain reproduced but does
not return with reduced SLR
• If pain does not recur:
– Tight hamstrings

83. Well-leg SLR test
p.348, Box 10-10
• Supine with knees
extended
• Passively raise one leg
– Similar to SLR test
– Raise leg with symptoms
– Provocation test
• (+)=Symptoms felt in
the other leg (“well”
leg)

84. Valsalva maneuver
p. 344, Box 10-6
• Increasing intrathecal
pressure to reproduce
symptoms
• (+)=Reproduced
symptoms :
Radiating pain or
Numbness

85. Kernig’s Test—p. 346
• Box 10-8
• Provocation test to
elongate the spinal cord
• Active SLR until point of
pain (knee straight)
• Flex knee @ point of pain
• (+)= pain in LB or radiating
pain in LE
• Brudzinski’s Test=Kernig
with cervical flexion

86. Hoover test
p.351, Box 10-13
• Tests compliance & effort
• “Malingering”
• Procedure:
– Supine with knees extended
– Active hip flexion
– Pressure should be felt on
opposite leg as SLR is
attempted
• (+)=No pressure=low effort

87. Babinski test
p. 383, Box 11-3
• Tests presence of upper
motor neuron pathology
• Blunt device moved across
plantar aspect of foot from
calcaneus to 1st metatarsal
head (great toe)
– (-)=toe flexion
– (+)=great toe extension with
splaying of other toes
• Normally (+) in newborns

88. Hamstring flexibility
• Tripod sign
• 90-90 position for
testing
• Tight hamstrings
pelvic tilt
Stretched extensors
Pain/spasm

89. Strength tests
• Isometric strength tests
• Held for 60 sec.
• Flexor strength testing
• Extensor strength
testing

90. Lifting Technique
• Maintain natural curves
– Sitting, standing, walking,
lifting
• 10:1 ratio
• Use large LE muscles
• Keep items close to body
• Hip = axis (not LS)
• Avoid rotating spine
• Get help when needed