OnExam
- Lumbosacral Spine Assessment
Inspection
- Inspect patient in standing and sitting, anteriorly, posteriorly and laterally
- Gait
- Posture and stance
- Muscle atrophy, spasm or increased tone
- Gluteal fold symmetry
- Iliac crest symmetry
- Approximate comparative leg length
- Lordotic lumbosacral curvature (excessive lordosis, flattening)
- Thoracic spine and hips for causes of lumbar spine issues
Palpation
- While patient standing note areas of pain, swelling, spasm, atrophy, deformity or crepitus in the following structures:
- Each lumbar spinous process
- Tenderness: fracture, infection, arthritis
- Step-offs: spondylolisthesis
- Facet joints deep in paraspinal muscles
- Paraspinal muscles
- Iliac crests
- Each sacroiliac (SI) joint at posterior superior iliac spine (PSIS) note symmetry
- Sciatic nerve
- Midway between ischial tuberosity and greater trochanter of femur
- Often best examined with patient lying on side and hips flexed
- Thoracic spine
- Hips
Percussion
- Percuss each spinous process from L1-L5 with the hypothenar aspect of a closed fist to suggest (or detect possible) malignancy, degenerative disease or osteomyelitis
- Malignancy
- Post-test probability if positive: 86%
- Specificity for malignancy: 60%
- Osteomyelitis
- Post-test probability if positive: 10.0% (LR+ = 2.1)
- Post-test probability if negative: 1.2% (LR- = 0.2)
Range of Motion
- Stand behind patient and stabilize hips
- Forward flexion (variable) “Touch your toes”
- Extension (normal = 30°), “Bend backwards”: Have patient place hands on their hips for stability
- Lateral flexion (normal = 35°), “Bend side to side”
- Rotation (normal = 30°), “Turn from side to side”
- Assess for motion between each vertebral segment (is it consistent or moving as a "hinge" in one area
- Ask patient to lie supine
- Assess for L5-S1 roots radicular pain
- Assess for sacroiliac joint pain
References
- Baxter S, ed., McScheffrey G, ed. Toronto Notes: Comprehensive Medical Reference & Review for MCCQE 1 & USMLE 2. 26th ed. Toronto: Toronto Notes for Medical Students Inc; 2010.
- Bickley L. Bate’s Guide to Physical Examination and History Taking. 10th ed. New York: Lippincott Williams & Wilkins; 2009.
- Filate W, Leung R, Ng D, Sinyor M, eds. Essentials of Clinical Examination Handbook. 5th ed. Toronto, ON. University of Toronto, 2005.
- Hurley K. OSCE and Clinical Skills Handbook. Halifax: Elsevier Canada; 2005.
- Pawa J, Lesniak, D., & Lott, A. Approach to the OSCE: The Edmonton Manual of Common Clinical Scenarios. Edmonton Manual; 2011.