This document provides guidance on diagnosing lumbar spine conditions in primary care. It notes that the history alone can establish many diagnoses, and the examination can be tailored based on clues from the history. Common lumbar spine issues involve the L4/L5 and L5S1 discs and nerves, presenting with pain or sensory changes in the lower back, buttocks, thighs, calves and feet. The examination focuses on assessing strength and sensation associated with the L2-S1 nerve roots. Findings may also indicate facet joint pain, spinal cord issues like abnormal reflexes, or cortical problems with non-dermatomal symptoms.

1. Diagnosing Lumbar Conditions in Primary
Care
Michael Bryant
Brizbrain & Spine

2. ? Dermatome
? Myotomes

3. Lumbar Assessment
• Can take as little as 3 minutes
• Time poor
– 10 minutes per patient
• History
• Management plan
• Where does examination fit in ?

4. History
• Many diagnoses are able to be established with
history alone
• Often exam can tailored looking for specific findings I
expect to see
• 80% of diagnoses from history alone

5. • Roughly 35% of lumbar problems at
L4/5 and 25% of problems at L5S1

6. L4/5 disc
• L5 nerve
– Buttock pain
– Pain or sensory changes
• lateral thigh
• Lateral calf
• Dorsum of foot
– Non specific clues
• Occasionally difficulties up stairs
• Stubbing toes

7. L5S1 Disc
• Pain or sensory changes
– Posterior thigh
– Posterior calf
– Sole of foot

8. L3 and L4 Nerves
• 30% of presentations
• Pains or sensory changes
– Lateral to anterior thigh to knee (L3)
– Lateral to anterior thigh to knee
then beyond to medial calf
• Nonspecific history
– leg collapsing (quadriceps)

9. L1 and L2 Nerves
• 5-10% of lumbar spine problems
• Groin pains (L1)
• Anterior Thigh pains (L2)

10. Examination

11. L2
• Hip flexors
• Pain/sensory changes in the anterior
thigh

12. L3
• Knee extensor weakness
• Reduced knee jerk
• Pain/sensory changes anterior thigh to
knee

13. L4
• Ankle dorsiflexion weakness
• (Possible) Reduced knee jerk
• Pain/Sensory changes anterolateral
thigh and medial calf

14. L5
• Great toe dorsiflexion wekaness
– Ankle dorsiflexion weakness
• Pain/sensory changes buttock/lateral
thigh/lateral calf/top of foot

15. S1
• Ankle plantar flexion weakness
• Pain/Sensory changes posterior
thigh/calf and sole/lateral aspect of the
foot
• Reduced ankle jerk

16. Facet Pain
• Pain in extension and rotation

17. Other Findings
• Spinal cord issues
– Brisk reflexes across the groups
– Extensor plantar response
– Go looking for sensory levels

18. Other Findings
• Cortical Problems
– Weakness or sensory changes across
multiple dermatomes/myotomes
– Often matching upper limb changes

19. Questions