The Spine
Lumbar Spine
p
• Anatomy
• Patho-Physiology
• Examination Garnet Tregonning FRACS, FRCS(C) Orth
Orthopaedic Service
Middlemore Hospital
ANATOMY
• Normal Curvatures
• Mobility
• “M ti S
“Motion Segment”
t”
• Nucleus Pulposis
• Annulus Fibrosis
• End-plate
NORMAL CURVATURES
• Lordosis - Cervical
- Lumbar
• Kyphosis -Thoracic
- Sacrococcygeal
• Normally curves “balanced”
balanced
• Abnormal - Scoliosis (3 planes)
- Kyphosis
K h i (Gibb
(Gibbus))
SPINAL MOBILITY
• Cervical
- Greatest
- Facet Joint configuration
- Trade-off for Stability
• Thoracic
- Flexion, Rotation,Lat Flexion
- Very Stable (effect of Ribcage)
• Lumbar
- Limited Flexion/ Rotation
(Facet alignment)
Lumbar
Limited Flexion/ Rotation
“MOTION SEGMENT”
• Anterior - Disc
• Posterior
P t i - Facet
F t
(Zygoapophyseal Joints)
• -Neural
Neural Arch
(Pedicle,”Pars”,Lamina)
INTERVERTEBRAL DISC
• Nucleus Pulposis
• Annulus Fibrosis
• End Plate
NUCLEUS PULPOSIS
• cf Hyaline Artic. Cartilage
• Shock Absorber/Joint
• Resists Compression
• Prone to Degeneration
• H i ti
Herniation
ANNULUS FIBROSIS
• Strong “Binder”
Binder
• Dense Collagen
g ((Type
yp 2))
• Elastin (less)
• Thinner Posterolateral
(H i ti )
(Herniation)
VERTEBRAL BODY
• Increases in size top to bottom
• Prone
P to
t Osteoporosis
O t i
• Wedge #s (Thor-Lumbar)
(Thor Lumbar)
• Endplate weaknesses –
Schmorl’s Nodes
• Metastases (adjacent to
Pedicles)
DEGENERATION
• Tends to start in Disc (20’s) !!!!!!
• Decreased Proteoglycan synthesis
• Drop
D iin water t content
t t - 88% Birth
Bi th
- 65% aged 75
• Increased
I d Collagen
C ll content
t t
• Discs - Stiffer
- less
l resistant
i t t tto ddeformation
f ti
- less able to recover
from Creep deformation
• Annulus more stressed
• Secondary effect on Facets - O/A
EXAMINATION
Lumbo/Sacral Spine
p
• Always involves Lower
Limb Neurology
• Applicable to rest of Spine
INSPECTION
• Starts when patient enters room
• Gait / In/out chair /sitting posture
/ undress
• Front, Back, Side
INSPECTION - FRONT
• Stance (“Sciatic”),Comfort
• Pelvic tilt / legg lengths
g
• Shoulders / Hips
• Muscle wasting
INSPECTION - BACK
• Scars, bruising, lumps,
spasm etc
• Hairyy ppatch/Dimples
p - Spinal
p
Dysraphism
• Sacral
S l region
i
• Curvature -
Scoliosis,Kyphosis
SCOLIOSIS
• Convex to L/R
• Rib / Paravertebral muscle
humps
• Look from behind with patient
p
bending over
• Sit to rule out LLD
INSPECTION - SIDE
• Kyphosis
yp
• Localised “ Gibbus
Gibbus” / Diffuse
• Lordosis / Flattening
PALPATION
• Identify levels
- Iliac
Ili C Crestt L 4/5
• Tenderness/spasm
• Prominence/Steps
- Spondylolisthesis
MOVEMENTS
• Active/Passive
• Flexion/Extension
• Lateral Flexion - sidebending
• Rotation
FLEXION
• Assess Hip vs Lumbar
- majority Hip
• Fingers to floor
• “Schober’s”
Schober s
measurement
EXTENSION
• Degree
• ”Spinal Rhythm”
y
• Hyperextension
GAIT
• Assess Limp
• Toe/Heel
• Spasticity
KNEEL
• Ankle Reflex (S1/S2)
• Comfortable
• If hyperreflexia
• Assess other reflexes (upper limb)
• Babinski
SIT
• Knee reflex L3/4
• Assess Quads power/bulk
• Indication
I di ti SLR (“Slump
(“Sl T
Test”)
t”)
LIE
• Look from foot of couch
• Posture - Sciatic
• Hips/knees flexed
NERVE ROOT IRRITATION VS ALTERATION
NERVE ROOT CONDUCTION
Straight Leg Raise
vs
N
Neurology
l
STRAIGHT LEG RAISE
• Irritation L5, S1, L4, S2
• One pillow Head
• Good side first - normal
- Positive
P iti “Crossover
“C test
t t
(“ Well leg raising test”)
• Watch FACE!
POSITIVE SLR TEST
• Lift leg with knee extended
• Reproduction of leg pain (NOT Back Pain!!)
• Assess degree
• LOOK AT FACE!!
PROVOCATIVE TESTS
• Only
O l perform
f if nott sure about
b tS Sciatica
i ti
• BOWSTRING (pressure Popliteal Fossa)
• Lasegue – passive dorsiflexion foot
• Flex
Fl neckk
FEMORAL STRETCH TEST
• L3, L4 (L2 rarely)
• Patient on side or prone
• Flex Knee/Extend Hip
• Positive - : Reproduction
ANTERIOR Thigh Pain
• Occasional Crossed Femoral Stretch Test
ALTERATION NERVE CONDUCTION
• Abnormal Neurology
gy
• Motor,Sensory,Reflex,Sphincter
• “Hard” vs “Soft”
“HARD” NEUROLOGY
• Wasting
• Reflexes
• Loss of Sphincter
MOTOR TESTING
• All muscle ggroups
p multiple
p Root innervation
• EHL/ EDL 90% L5
• Some individual
variation
i ti
L 5 ROOT
• MOTOR
– EHL EDL Foot Drop
– Hip Abductors
– Heel Walk
• SENSORY
– Dorsum Foot/Toes
– Ant-Lat
Ant Lat Calf
S1
• MOTOR
– Toe walk / Tip Toe
– Gastroc/Soleus
– Peronei - Brevis - Foot Eversion
- Longus
g - Depression
p 1st Rayy
• SENSORY
– Lat
L t bborder
d ffoott 4/5 ttoes
– Post/Lat calf
• REFLEX
– Ankle S1/2
– Kneeling best
L4
• MOTOR
– Quads
– Tib Ant L4/5
• SENSORY
– Ant Lat Thigh
Thigh, Ant Med Calf
• REFLEX
– Knee L 3/4
– Sit relaxed side of couch
SPHINCTERS S 4
• Voluntary/Involuntary
contracture with Rectal
• Anal,Perianal Sensation
CAUDA EQUINA SYNDROME
• Incontinence
• “Saddle Anaesthesia”
• Absent Anal Sphincter Tone/Contracture
UPPER MOTOR NEORONE LESION
• Spasticity, Hypertonicity
• Hyperreflexia
yp
• Babinski
• BulboCavernosus
C Reflex
f
The End
