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on the examination table with the hands behind the head. The patient is then asked to lift the chest off the table (Fig. 9-14). Again, the height that the shoulders rise off the

laterally, the transver.se processes are also located deep to the paraspinous muscles and are not distinctly palpable. Howcvcr, the finding of localized unilateral tenderness deep to the paraspinous muscles following trauma should suggcst the possibility of a transverse process fracturc.

Pain originating in the lumbar spine must frequently be distinguished from pain originating in the sacroiliac joint, the posterior pelvis, the hip, or the thigh. Exam-ination of the lumbar spine should, therefore, include palpation of the sacrum and the coccyx, the sacroiliac joint, the sciatic notch, and the other bony and soft tissuc structures of the posterior pclvis, the hip, and the thigh. The palpation of thcsc structures is described in Chapter 5, Pelvis, Hip, and Thigh.

■ MANIPULATION

Muscle Testing

Strength testing of the muscles that move the lumbar spine is not usually emphasized. Nevertheles$, the abdominal and the lumbar musculature fulfills an important role by

_ Chapter 9_Lumbar Spine 345

rcducing the load on the static elements of the spine. A generał assessment of the function of these muscle groups is, therefore, helpful in evaluating the common strain and overuse disorders that are frequent causes of Iow back pain.

Flexion of the lumbar spine is powered by the abdom-inal muscles, particularly the rectus abdominis. The function of these muscles may be assessed by having the patient pcrform a crunch, or modified sit-up. In this exercise, the patient lies supine on the cxamination table with the hip and the knecs flexed, hands behind the head. The patient is thcn instructed to raise his or her shoulders off the table (Fig. 9-13). The hcight to which the shoulders can be raised and the number of repetitions possible vary tremendously among individuals according to flexibility, fitness levcl, and prior training. A patient who cannot raise the shoulders even once has significantly weak abdominal muscles.

Extcnsion of the lumbar spine is powered by the crector spinać muscle groups. To assess the function of these muscles, the patient is placed in the prone position

9-2 • When the Patient Complains of Low-Back Pain after Trauma

Major Diagnostic Possibilities Include:

•    Fracture

•    Ligamentous injury

•    Low-back strain/sprain

•    Herniated disk

May be necessary to rule out underlying pathologic lesion of the vertebra such as tumor or osteoporosis.

Ask the Patient to Describe the Original Injury Episode:

•    Major trauma such as a motor vehicle accident or a fali from a height with immediate pain

-    Exclude fracture or ligamentous injury

•    Minor trauma such as a lifting or twisting injury

-Consider low-back strain/sprain, vertebral compression fracture in osteoporotic patients or herniated intervertebral disk

Ask the Patient to Describe their Current Symptoms:

•    Constant low-back pain, madę worse with any activity

-    Exclude fracture or major ligamentous injury

•    Low-back pain, madę worse with bending or twisting

-Suggestive of a low-back strain/sprain

-    Herniated disk, fracture, or ligamentous injury remain possibilities

•    Low-back pain associated with radiating leg pain, paresthesias or weakness

-    Indicates likely neural compression arising from herniated disk, fracture, or ligamentous injury with neural encroachment or injury

•    Low-back pain associated with bowel or bladder symptoms

-    Suggestive of a large herniated disk with associated cauda equina syndrome (a surgical emergency)

- May be caused by fracture or ligamentous injury resulting in neural compression or cauda equina injury

Relevant Physical Examination:

General:

•    If suspicious of spinał fracture or dislocation, immo-bilize patient and assess for hemodynamic stability and other associated injuries

•    Inspection

•    Examination of gait

•    Rangę of motion

Fracture or ligamentous injury:

•    Inspection for swelling and ecchymosis at the level of injury

•    Palpation for tenderness at the level of injury

•    Palpation for step-off

•    Neurologie testing for associated upper or lower motor neuron deficits

Low-back strain:

•    Palpation for paraspinal muscle tenderness or spasm

•    Inspection of gait for list (variable)

•    Rangę of motion typically painful

•    Neurologie examination typically normal

Herniated disk:

•    Flexion of lumbar spine to reproduce leg symptoms

•    Palpation of sciatic notch for tenderness

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

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