Lumbar Spine Examination

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Standing

  • Gait
  • Stature
  • Build
  • Romberg
  • Transitioning movements
  • Posture and alignment
    • Thoracolumbar alignment coronal and sagittal plane
    • Lumbar alignment coronal and sagittal plane
    • Pelvic alignment
    • Foot alignment
  • Movement
    • Forward flexion
    • Extension
    • Side flexion
    • Compound extension and rotation
  • Trendelenburg

Sitting

  • Breathing
  • Pelvic alignment
  • Slump test

Lying

  • Skin drag and rolling
  • Allodynia to cold and pin prick
  • Palpation
    • Vertebral springing tenderness
    • Rotation testing
    • Bony landmarks: Iliac crest, PSIS, LPSL, sacroiliac joint
    • Soft tissue: sacrotuberous and sacrospinous ligaments, gluteus medius and gluteus minimus, piriformis, iliopsoas, quaratus lumborum, hamstring origin
  • SIJ provocation testing: distraction, thigh thrust, sacral thrust, compression
  • Hip joint range of motion
  • Special tests
    • Straight leg raise
    • Femoral stretch test
    • Iliopsoas length test and tenderness
    • Direction preference
    • Centralisation phenomenon
  • Neurological examination
    • Tone
    • Power: hip flexion (L2), hip adduction (L3), ankle dorsiflexion (L4), great toe extension (L5), knee flexion (S1)
    • Reflexes: knee (L3, L4), medial hamstring (L5), achilles (S1) [1]
    • Sensation: L2, L3, L4 (medial lower leg 88%), L5 (first dorsal digit 82%), S1 (lateral 5th digit 88%), S2, S3 [2]
    • Plantar reflexes

Paediatric Examination of the Whole Spine

A consensus approach to the MSK examination in children was developed by Foster et al in 2011.[3] They did not differentiate between cervical, thoracic, and lumbar spine. The underlined components are those that are additional to the adult examination. The italicised components are those that the doctor should be aware of but not necessarily competent in.

With the patient standing:

  • Look at the spine from the side and from behind
  • Look at the skin and natal cleft
  • Look at limb and trunk proportions
  • Look at the face and jaw profile
  • Feel the spinal processes and paraspinal muscles and Temporomandibular joints (TMJs)
  • Assess movement: lumbar flexion and extension and lateral flexion; cervical flexion, extension, rotation and lateral flexion, thoracic rotation
  • Assess TMJ opening 
  • Options – Schober’s test, “stork test”

With the patient sitting on couch (standing in younger child):

  • Assess thoracic rotation

With the patient lying on couch:

  • Perform straight leg raising and dorsi-flexion of the big toe
  • Assess limb reflexes
  • Option – leg length, hypermobility, sacroiliac joint palpation (Faber’s / Patrick’s test)

References

  1. Esene et al.. Diagnostic performance of the medial hamstring reflex in L5 radiculopathy. Surgical neurology international 2012. 3:104. PMID: 23087820. DOI. Full Text.
  2. Nitta et al.. Study on dermatomes by means of selective lumbar spinal nerve block. Spine 1993. 18:1782-6. PMID: 8235861. DOI.
  3. Foster et al.. Pediatric regional examination of the musculoskeletal system: a practice- and consensus-based approach. Arthritis care & research 2011. 63:1503-10. PMID: 21954040. DOI.