L4, L5, S1- see pic near end of notes.doc.doc.doc.doc
Cara Beth Lee, MD
Also Check out Jacob’s Website of Class Notes
Exam next week
25 multiple choice 2 points each,
50 points of short answer
5 questions per lecture for M.C. and 10 points per lecture for short answer.
The test will be PE stuff, For example: What PE would you do to confirm your DDx? She will be more
testing your thought process not how you do a certain test. No x-ray views. Wants the test to be straight
forward and test your thought process. So it will be mostly Dx.
Red Flags- know these
Won’t ask numbers and percents, won’t be tested on Algorithms at end of these notes.
Can switch sections for exam
Sample Question: Multiple Choice
After a PE and Hx you think patient has L5 radiculopathy. On Exam you would expect to find
1. Weakness of ankle dorsiflexion
2. Decreased sensation of medial malleolus
3. Decreased achilles tendon reflex
4. Decreased extension of Great toe
2nd test In that patient
Where would you expect their herniation to be?
1. L4-5 right answer. (b/c it’s the traversing nerve root L4 has already exited so L5 is the
nerve that has been compressed)
Sample Question: Short Answer
You are worried someone has cauda equina syndrome
tell me 3 things you will see on Hx and Pe? Make sure you know red flags.
Key is to test 3 nerves for Ruling Out Red Flags if a patient comes in with Low Back Pain.
L4, L5, S1- see pic near end of notes
Test motor, sensation, and DTR’s of each nerve.
• Motor-active and resist ankle dorsiflexion
• Sensation-medial malleolus
• Motor-big toe dorsiflexion and resist
• Sensation-dorsum of foot
• Motor- plantar flexion and resist
• Sensation-lateral malleolus
• DTR- Achilles tendon
Physical Exam she does, R/O red flags first and put patient in gown, (not on test per say but
good to know how she does it)
1. Walk- watch and them walk on toes(S1gastroc and soleus’plantar flexors’, and great toe
flexors, peroneous longus and brevis), and then on heels (L4’ankle dorsiflexion’ L5
great toes dorsi-flexion), walk as though on balance beam. (balance problems could be a
myelopathy not necessarily cauda equina), look if weak mm. weakness.
2. Sit-have feet dangling, test straight leg raise (SLR), at 90 degrees first,
a. Motor first have them lift knee and resist, push knees towards away, then with
lower leg extend and flex, lat. And med movement, push against big toe
dorsiflexion(L5), sensation at dorsum of foot, push down on gas(S1, peroneus
longus and brevis) achilles tendon reflex and sensation- lateral malleolus, curl
big toe under, ankle dorsiflexion(L4ant. tibialis) DTR of L4-patellar sensation
over medial malleolus,
b. Test goes ankles up, ankles down, big toe up, sensation touch medial malleolus,
lateral malleolus, top of foot, two reflexes Achilles and patellar.
c. Sensation, compare feet, test behind knee too
d. Patellar, Achilles, and babinski, DTR, clonus(myelopahty)
3. Lay Supine- SLR(straight leg Hip ROM, repeat motor tests if weak sitting.
• lifetime prevalence of low back pain 50% - 80%
• most common cause of disability in age < 45
• 15 million patient visits per year-many to PCPs
• total annual health care costs up to $20 billion- includes loss of work
• 90% spontaneously recover within 1 month- no matter what we do they get better
A little bit about back pain
• Classification based on duration
o +acute – immediate onset, duration < 3 months
o subacute – slow onset(key diff), duration < 3 months
o chronic – duration > 3 months
o recurring – symptoms recurring after interval of no symptoms
• Classification based on location
o local – pain in lumbar or lumbosacral area low back pain
o referred – pain located in area that shares common embryologic origin with the
involved region (myotomal or sclerotomal), ex: heart attack, pain down left arm ex L4
bone pain pattern groin pain is hip joint arthritis for example.
o radicular – pain located along dermatomal distribution due to direct irritation of spinal
nerve root (radiculopathy, sciatica)
• What hurts?
o superficial support structures skin, fascia, muscle and ligaments may produce local
pain if injured or overused
o unanesthetized stimulation study-put in sutures and pulled on them did that hurt?
localized back pain
• annulus fibrosis (not nucleus pulposus)
• vertebral endplate
• anterior dura
• posterior longitudinal ligament
• facet capsule
irritated nerve root radicular distribution. Radiation only if irritated if not it
just hurt locally. The key is radicular pain. Theory substance P, or immune
response-usually non-vascular so when there is immune response there is fluid
that usually isn’t there.
• mechanical deformation, reduction of blood flow
• chemical exposure
• autoimmune or inflammatory response to nucleus pulposus
Osteology: Lumbar spine
• vertebrae- flexion and extension, rotation is mostly thoracic, Pars interarticularis-a stretch of
bone between the verterbrael bodies(more on this below).
• low energy (osteoporotic)-cough or sneeze too hard can fracture
o stable fractures
o treat symptomatically-pain NSAIDs, OTC braces, calcitonin – can help
• high energy-MVA, or falls from height.
o stable vs. unstable (not on test) dividing up the vertebral
o (Not on Test -NOT)three columns anterior, middle, posterior column, post. 1/3 is
spinous process. Ant. 1/3 is post part of vertebral body.
o unstable = involvement of more than one column
o Ex-snowboarding, burst of disc into spinal canal, Tx-surgery
Spondylolysis-risk factor for spondylolisthesis
• defect in bony arch between inferior and superior articulating processes (pars interarticularis)
loss of pars interarticularis
• typically L5-S1
• present in 5% of general population-most asymptomatic, less than 1% have sx
• “congenital “ vs. acute – congenital should be found young
• gymnasts, football linemen- typically more acquired though. Cause is hyperextension bending
force cracks it.
• Classic will be gymnast with LBP and increasing pain
• may be inherited
• Tx- symptoms may respond to bracing and activity modification,
• If recurrent rare surgical fusion
• Dx- oblique x-ray- look for collar of Scotty dog, have to see pic, and x-ray
Spondylolisthesis- a continuation of pathology of spondylolysis, spondylolisthesis- is just
movement or slippage of vertebrae. Have to have spondylolysis to have spondylolisthesis.
There are other causes of spondylolisthesis. Spondyloptosis is stage 5 of spondylolisthesis all
the way slipped off of vertebrae. Spondylolysis- may be able to heal,
• forward subluxation of one verterbra on another, post. Elements stay back.
• implies bilateral spondylolysis
• vertebral body translation may be acquired, related to disc degeneration and not spondylolysis
• most slippage occurs during adolescent growth spurt
History and Physical Exam in children
• May occur at growth spurt- boys 14 girls 12 yo.
• ± pain, may radiate to buttocks
• postural change- increase lumbar lordosis, change in posture,
• hamstring tightness
• stiff-legged gait with short stride length
• decreased straight leg raise-
• mild discomfort to palpation
• increased lumbar lordosis
• rule out bowel / bladder dysfunction, sacral / rectal dysesthesias
History and Physical Exam in adults
• usually presents with pain-especially in adults.
• pain patterns similar to disc herniation or spinal stenosis
• lumbar lordosis and hamstring tightness
• history and physical exam- increase lumbar lordosis
• standing AP, lateral, oblique can see it laterally and do a grading depending on how far the
vertebrae falls off the vertebrae below it.
• adults may need CT or MRI to evaluate other sources of pain- they have other things
• incidental finding no restriction especially if no pain.
• acute symptoms
o activity modification / restriction
• hamstring stretching – can help a lot.
• consider bone scan(only spondylolysis b/c it can heal itself if the vertebrae is slipped off then it
can’t heal) - with a hot bone scan(laying down new bone) then a good sign healing is happening
and may heal themselves.
• follow with spot lateral x-ray every 6 months until skeletally mature
• surgery in situ fusion- where it is not move it back b/c the nerves and
o failure of non-operative treatment
o slip of greater than 50% in kids- want to stabilize this, don’t want it to progress.
o address other pathology in adults
o Can screw sacrum and L5 together.
o Questions-could this be adjusted- manual adjustment won’t do it. Surgery in situ
fashion is Tx. If you move the verterbrae back the nerves may be impinged because
they have grown differently to accomadate, and moved anteriorly with the slippage of
the vertebrae. So moving back the vertebrae impinges on the nerves, rather than moving
the vertebrae back into place the approach is to not let the vertebrae move any farther.
Screw them in place where they are at.
Scoliosis (rotatory kyphoscoliosis)- bend to vertebral elements as well.
• 80% of cases are adolescent-onset idiopathic some are congenital due to lack of growth of
• B. is not misshapen- on x-ray looks like loss of disc space(not true though), Soft tissue as well
but not really just that, bottom line-its poorly understood.
• affects 2%-3% of 10- to 16- year olds few require tx
• Lower degree curves boys and girls equal.
• ♀10 : ♂1 for curves > 30°
• convex to the right
• If convex to left-- higher associated with other neurological problems need more work up.
• Can have two curves
• less than 10% require active treatment
• risk factors for curve progression:
o younger age at diagnosis- more likely to progress b/c more growth remaining to do .
Risser stage- radiographic method of Tanner staging(secondary sex char.) 25%
of iliac crest is covered. Ex 40degree curve and Risser 1 they still have a lot of
growth and so will progress.
o double-curved patterns
o larger curve at detection
Curve magnitude Age
at detection 10-12 13-15 16
< 19° 25% 10% 0%
20° -29° 60% 40% 10%
30° -59° 90% 70% 30%
> 60° 100% 90% 70%
• screening exam indicated in all school age kids
• scoliometer measurement > 7° an indication for x-ray How to use scoliometer =(pic on
ciprianno238) lay this scoliometer on most curved part of back with patient bent forward
• minimal asymmetry examine q 4-6 months
• radiographic curve > 25° begin bracing
o goal is to stop curve progression (not absolute correction)
o bracing ineffective with curve > 40°
• curve > 50° surgery- long Herrington rods T-5 into lumbar spine hook onto lamina force
back straight, diminishes motion,
• curves > 50° tend to progress throughout life
• 90degrees will impinge on pulmonary function.
• How to look at X-ray- measure with a line Include a diagram
• Ex- patient at Bastyr clinic who got symptomatic relief with heat, and massage tx spine was
straight on table when she stood it was off center again.
Disc protrusion / herniation
Nucleos pulposus-90% water,
• 20% of asymptomatic subjects have protrusion/herniation by age 60
• 2% lifetime prevalence of symptomatic disc disease
o 10 – 20% with persistent radiculopathy may benefit from surgery
• bulging but intact annulus fibrosis indicator of wear and tear, and loss of water content, 70%
water content when older
• gradual loss of disc water content with aging
• risk factors for protrusion
o sedentary work
o family history
o occupational exposure to vibration- hard labor in younger years strengthens though.
• negative risk (i.e., protective) factors
o manual work in younger years
o diabetes (risk factor for degeneration but not protrusion)
o spondylolisthesis-not as much of a factor for nerve root compression, slip, it opens up
canal space, reverse of spinal stenosis.
• symptoms depend on canal space
• disc herniation nucleus pulposus pushes through a tear in the annulus fibrosis
o typically occur on a side due to thick central PLL
History (protrusion and herniation)-nucleus material into foramen
• acute or subacute
• low back / buttock pain may radiate in a radicular pattern if compressing nerve root
• symptoms exacerbated by valsalva (cough, laugh sneeze)
• trunk list that improves when supine(leaning off center to relieve compression)
• limited straight leg raise
• L4-5 its L5 nerve that’s affected
• over 80% of patients respond to conservative care
• no statistically significant difference in long-term outcome of operative vs. conservative
treatment for mild radiculopathy, benefit of surgery is shorter rehab and shorter recovery
• analgesics, muscle relaxants, NSAIDs
• epidural steroid injection
• walking, conditioning
• Bed rest longer than 3 days is detrimental
• abdominal and low back strengthening once able
• return to sedentary work 6 – 8 weeks with lifting restriction
o persistent or recurrent radiculopathy
o increasing impairment
o gross motor weakness
o resolution of symptoms 90% in appropriately selected patients
Cauda Equina Syndrome RED FLAG of LBP
• Key- difference between this and disc protrusion is that this is disc
protrusion into whole spinal cord is and so more severe sx and
• Cord ends at L1, sacral nerve roots, bowel and bladder control perineal sensation
• compression of cauda equina typically due midline disc herniation
• rare, 1% to 2% of lumbar disc herniations
• can be caused by lifting, or MVA,
• urinary retention
• bowel / bladder incontinence
• “saddle” anesthesia-sacral nerve roots
• unilateral or bilateral radiculopathy
• sensory and motor deficits
• decreased sensation on wiping,
• diminished anal sphincter tone
• surgical emergency
o deficits untreated > 48 hours may be permanent
Narrowing of vertebral canal, due to thickening of lig. Flavum, hard discs btwn vert. bodies. Stable
fractures if involve only one column
• congenital vs. acquired
• usually acquired (degenerative)
o vertebral bar (hard disc)
o thickened facet joint and capsule
o osteophytes- around facet joints.
o ligamentum flavum hypertrophy
• degenerative spondylolisthesis – loss of disc height allows anterior-posterior translation of
• spinal stenosis two clinical syndromes (activity-related mechanical back pain in each)
1. root entrapment
o radicular pain – LBP as well, diff from disc herniation
o not changed by valsalva
o may have normal exam: nl SLR, reflexes, motor and sensory function
o nerve root is tight but not irritated
o symptoms worsened with back extension, flexion or straight leg raise is ok relieves sx.
o natural history is improvement
2. neurogenic claudication
o thought to be due to venous congestion in cauda equina which decreases nerve root
o unilateral or bilateral
o limitation of walking distance-cauda equine delaying nerve conduction.
o DDx from vascular claudication- check peripheral pulses, or stationary bike test no
probl but a vascular claudication will b/c the crouched position.
o improved with forward bend
o natural history is gradual decrease in activity level
o CT scan
• activity modification
• moist heat
• isometric flexion exercises-open spinal canal.
• aerobic conditioning (biking, swimming)
o failure to respond to nonoperative treatment
o progressive neurologic deficit
o leg pain > back pain (back pain comes from different degenerative processes)
o success rate 60% - 70% (often because of multi-level stenosis)
Sprain / Strain
• indistinguishable from each other clinically
• manifest as lumbar and paraspinal pain
• muscle tightness or spasm
• pain shouldn’t radiate
• 90% get better on their own
• cold, massage, ultrasound
• heat after 48 hrs
• analgesics and muscle relaxants
• activity modification
• majority are metastatic
• If goes to b. it goes to vertebral bodies.
• nighttime or rest pain, progressive
• exacerbated with percussion
• Hx-biggest key hx of malignancy
• bone scan
• very rare
• may affect disc space or vertebral body
• hematogenous or post-surgical in adults kids may not have hx.
• h/o UTI, urinary surgery, dental abscess, IVDA, immune suppressed
• nighttime or rest pain, insidious, progressive
• pain exacerbated with percussion
• check CBC, ESR, blood culture
• biopsy for culture / pathology
• early antibiotics
Estimated prevalence in 100 primary care patients
• 85 – nonspecific low back pain- so
• 4 – vertebral compression fracture(little old ladies with osteoportic compression fracture)
• 3 – spondylolisthesis
• 2 – herniated disc
• ? – spinal stenosis
• 0.7 – malignancy
• 0.3 – ankylosing spondylitis
• 0.01 - infection
AHCPR –agency for health care practice guidelines(developed in 1991)- some patients are over
or under studied before Dx, so a group of a bunch of different therapists, from psychologist to
massage therapists, to orthopedic surgeons. They reviewed articles, and then presented
guidelines of how to manage patients.
AHCPR-since 80% are nonspecific so rule out whats worrisome, most get better with conservative
care. Just support people through back pain. This is a list to help you with your thought process as a
PCP with a patient who comes in with LBP.
Low Back problem =Defined as activity intolerance
Focus on acute sx <4 weeks,
• goal – “paradigm shift”-rather than label with
• multi-disciplinary panel
• evidence-based guidelines
• targets primary care provider
• low back problem: activity intolerance due to back-related symptoms
• duration less than 3 months
• avoid labeling- don’t just tag things.
• seek “red flags”- make sure nothing major going on.
• medical history guides physical exam just focus in on what you think is going on.
• focused physical exam
• regional back evaluation-ROM not helpful (cheating motion through pelvis), look at back look
for mm. spasm, then test following 4 nerve roots with motor, sensory, and reflex.
• sensorimotor exam of L4, L5, S1- 80% of problems affect these problems
• straight leg raise test-most useful test, for rule outs
• in the absence of red flags, no testing is needed in the first month of symptoms
• provider’s responsibility is reassurance and education
• algorithms provide pathway and time frame for next steps
Red Flags For Conditions(cancer, infection, cauda equina, fracture) If no Red Flags for Low
Back Pain then no extra tests are needed, no x-ray, CT, MRI for first month. Instead just reassure them
this will get better with time and give back care and education about back care and safety.
Red flags for cancer or infection
• age > 50 years
• history of cancer
• unexplained weight loss
• immunosuppression / corticosteroids
• IV drug use
• urinary tract infection
• nighttime symptoms
Red flags for fracture
• age > 70 years
• history of major trauma in young
• history of minor trauma in elderly
Red flags for cauda equina syndrome
• saddle anesthesia-area of perineum that’s touching a saddle when sitting on it, affects these
• urinary retention / overflow incontinence
• fecal incontinence / loss of sphincter tone
• progressive motor weakness
NPLEX(not tested for- won’t be asked to explain Milgram’s test for example)
• tests that increase intrathecal pressure to test for space-occupying lesions
o Valsalva test (80,285Ciprianno) – ask patient to bear down as if straining to have a
bowel movement, subjective
o Naffziger test (287) – compress jugular veins and hold for one minute pain in lumbar
region is positive, may recreate radicular pain if nerve root involved
o Milgram’s test (286) – instruct supine patient to raise legs several inches off table and
hold for 30 seconds, pain is a positive result
• tests that increase nerve root tension
o Straight leg raise test (266) – patient supine, maintain knee extension, flex hip to point
of pain or 90 ° pain 0 ° – 35 ° suggests extradural sciatic irritation, 35 ° – 70 °
radicular pain from disc pathology, 70 ° – 90° lumbar joint pain
o Kernig’s test (430) – patient supine, flex hip and knee to 90 °, then instruct patient to
extend the knee, positive if symptoms occur with extended knee OR flex head
o Bragard’s test (271) – patient supine, raise affected leg to the point of pain, then lower 5
° and dorsiflex foot dorsiflexion pain from 0 ° – 35 ° suggests extradural sciatic
nerve irritation, 35 ° – 70 ° nerve root irritation
o Lasegue’s test (267) – patient supine, flex hip and knee, then, keeping hip flexed,
extend the knee positive for radiculopathy or sciatic stretch if symptom free with
knee flexed and painful with knee extended
o Minor’s sign – ask seated patient to stand, a patient with radiculopathy will stand with
his/her weight on the healthy side and keep affected leg flexed to decrease nerve tension
• tests that increase nerve root tension
o Bectherew’s test (274) – patient seated with knees flexed over exam table, ask patient to
extend each knee separately, then together positive is knee extension recreates
radicular pain or causes patient to lean back
o Fajersztan’s / well leg raise (273) – patient supine, raise unaffected leg to 75 ° or the
point of pain and dorsiflex the foot stretches well- leg AND affected leg nerve root,
may help differentiate lateral from medial disc
o Kemp’s test (282) – patient seated or standing, with one hand stabilize PSIS, with the
other, reach around the front of the patient and grasp the shoulder, then passively extend
the lumbar spine obliquely lateral disc lesion will increase nerve root tension with
ipsilateral oblique bend, producing radiculopathy; medial disc lesion will recreate
symptoms with motion in the contralateral direction
• tests for malingering / symptom magnification
o Hoover’s sign (426) – ask supine patient to raise affected leg while you cup the heel of
the other foot, if patient is exerting effort to raise his leg, the opposite foot should press
down into your hand
o Burns bench test (427) – have patient kneel on a bench or exam table and bend at waist
to touch the floor as you stabilize the legs, patients with low back pain should be able to
perform this test because the stress is placed on the posterior leg muscles
Cipriano JJ, Photographic Manual of Regional Orthopaedic and Neurological Tests, 2003.
Crowther CL, Primary Orthopedic Care, 2004.
Hoppenfeld S, Physical Examination of the Spine and Extremities, Appleton-Century-Crofts, 1976.
Netter F, Atlas of Human Anatomy, Ciba-Geigy Corporation, 1989.
Weinstein JN, Rydevik BL, Sonntag VKH, Essentials of the Spine, Raven Press, 1995.
www.chirobase.org – AHCPR Clinical Guidelines
www.ncbi.nlm.nih.gov – AHCPR Clinical Guidelines