REIDER PART 2
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Rangę of Motion

Motion of thc lumbar spine is the result of a complex interaction among bony structures, articulations, and soft tissucs. Abnormalities of any of these structures may limit the rangę of motion of the lumbar spine. The loss of motion may be due to pain, muscle spasm, mechanical błock, or neurologie deficit. Rangę of motion of the lumbar spine is traditionally evaluated with the examiner standing or seated behind the patient. However, thc exam-iner may also need to look from the side to morę easily quantify the amount of flexion and extension present.

_Chapthr 9__Lumbar Spine 341

Flexion

To assess the flexion of thc lumbar spine, thc patient is asked to bend straight forward at the waist as far as pos-sible (Fig. 9-7). Depending on the amount of fiexibility present, the patient may be instructcd to attempt to touch the fingertips or the palms to the floor. The amount of flcxion present is estimated as the angle between the finał position of the trunk and a vertical piane. Thus, 90° of flexion is present when the patient s trunk is parallel to thc floor. When measured in this fashion, flexion averages about 80° to 90°.

9-1 • When the Patient Complains of Low-back and Leg Pain

Major Diagnostic Possibilities Include:

•    Herniated disk

•    Spinał stenosis

•    Spondylolisthesis

•    Infection

•    Tumor

Patient Demographics:

•    If the patient is less than 20 years old

-    Infection, tumor or spondylolisthesis morę likely

•    If the patient is 20 to 50 years old

-    Herniated disk, spondylolisthesis morę likely

•    If the patient is older than 50

-Spinał stenosis, spondylolisthesis, herniated disk morę likely

Obtain Relevant Medical History:

•    If the patient is immunocompromised or has a history of intravenous drug abuse

-    Infection is a strong possibility

•    If the patient has a history of cancer

-    Metastatic spread to the lumbar spine must be suspected

•    If the patient has a history of repetitive hyperexten-sion of lumbar spine (e.g., gymnast or football lineman)

-Spondylolisthesis is possible Ask the Patient about the Onset of Symptoms:

•    Sudden onset

-    Morę suggestive of herniated disk, infection, or tumor

•    Gradual, insidious onset

-    Spinał stenosis likely

Ask the Patient to Describe Associated Symptoms:

•    Constitutional symptoms such as weight loss, fever, or night sweats

-    Suggestive of tumor or infection

•    Unilateral leg paresthesias, weakness, or pain

-Typical of herniated disk

•    Bilateral buttock/leg pain and cramping with ambulation

-Suggestive of spinał stenosis

•    Bowel or bladder symptoms

- Cauda equina syndrome from a midline disc herniation a possibility and must be ruled out as it is a surgical emergency

•    Pain worse with ambulation but relieved with sitting, bicycling, or activities where lumbar spine is flexed

-Suggestive of spinał stenosis

Relevant Physical Examination:

General:

•    Inspection

•    Examination of gait

•    Rangę of motion

Herniated disc:

•    Nerve root tension tests (straight-leg raising, Lasegue's test, contralateral straight-leg raising, slump test, bowstring sign)

•    Flexion of lumbar spine to reproduce leg symptoms

•    Palpation of sciatic notch for tenderness

•    Neurologie testing for deficit in the distribution of the involved nerve root

Spinał stenosis:

•    Decreased lumbar rangę of motion

•    Leg symptoms reproduced with lumbar spine extension

•    Neurologie testing for deficit in the distribution of the involved nerve root

Spondylolisthesis:

•    Inspection for decreased lumbar lordosis

•    Hyperextension of lumbar spine may reproduce back pain; relieved with flexion

•    Palpation for step-off

•    Straight-leg raising test to elicit hamstring tightness

•    Neurologie testing Infection/Tumor:

•    Palpation for point tenderness at involved level

•    Palpation for associated muscle spasm

•    Neurologie testing