Orthopedics- Lumbar lab

Question 1

Describe valsalva and what it can help you r/i or r/o

Answer 1

have the pt bear down with ‘all their might’

if (+) can indicate there is nerve root irritation

Question 2

Describe Bechterew’s test and what a (+) test is and what it could indicate

Answer 2

seated straight leg raise- actively or passively extend one leg at a time to ~ 90 deg, if have dermatomal sxs when passively bring up then that is a (+) or if no sxs then extend both legs
(+) = sxs down posterior thigh past knee; this could indicate L4, L5 or S1 radiculopathy dt herniated disc, stenosis, osteophytes, tumors, infxns or fracture

Question 3

Describe Slump test, what it’s testing for, what a (+) would be and what it could mean

Answer 3

1. Have pt seated w/arms behind back
2. pt slumps w/cervical extension
3. cervical spine is fully flexed and released (cervical flexion/extension performed by examiner)
4. one knee is maximally extended then cervical spine is fully flexed and released (cervical flexion/extension performed by examiner)
5. dorsiflex ankle then cervical spine is fully flexed and released (cervical flexion/extension performed by examiner)
   if (-) sxs then hold both of pts legs and them then flex and extend and then dorsiflex the feet w/cervical flexion and extension to see if can produce a (+)
   this test is to test for sciatic nerve tension or lumbar disc herniation

Question 4

Describe Kemp’s test, what a (+) is

Answer 4

trunk extension, lateral flexion and slight ipsilateral rotation around doc’s hand
(+)= low back pain w/ or w/o pain radiating down leg; numbness, tingling or pain in dermatomal pattern of L5
if (+) with radiating sxs could indicate nerve root compression
if (+) w/o radiating sxs could indicate muscle/ligamentous strain or facet irritation/capsular inflammation

Question 5

During Kemp’s test what could radiating pain indicate? local pain w/o radiation?

Answer 5

radiating pain could indicate nerve root compression
local low back pain w/o radiating pain could indicate a muscle or ligamentous strain, facet irritation or capsular inflammation

Question 6

Describe SLR test; what do you need to ‘note’ during this test?

Answer 6

doc passively elevates the pts leg while keeping it straight

NOTE: angle of onset of pain

Question 7

what would a ‘hard’ positive during SLR test look like and indicate? a ‘soft’ or ‘equivocal’ positive? a negative test? focal point of pain in leg or pelvis?

Answer 7

‘hard’ positive: sharp, burning, electrical pain past knee w/hip flexed 35-70 deg; could indicate sciatic nerve irritation/L4-S1 nerve roots radiculitis from herniation, tumor, spinal canal stenosis or osteophytes
‘soft’ positve: pain radiating into lower extremity but not past knee; could indicate nerve root or sciatic nerve inflammation/compression, only considered meaningful if other evidence suggests nerve root or sciatic nerve compression
negative: no pain, pain in back or pain to buttocks; could indicate that there is no nerve root involvement, most likely sacroiliac or lumbar
focal point: “alarm” sign–> suggests a tumor in location of pain

Question 8

Describe Sicard’s test, what is a (+), what could it indicate?

Answer 8

if passive SLR is (+) then lower leg 5-10 deg below pain and dorsiflex the big toe
(+)= duplication or increase of radicular leg pain
could indicate sciatic radiculopathy or nerve root compression

Question 9

Describe Bragard’s test, what is a (+), what it could indicate?
what can it confirm?

Answer 9

if passive SLR is (+) then lower leg 5-10 deg & dorsiflex the foot
(+)= duplication or increase of radicular leg pain
could indicate sciatic radiculopathy, disc herniation, encroachment or SOL
can confirm that sxs are coming from the nerve root

Question 10

Describe Well leg raise, what is the other name? what is a (+) test? what could it indicate?

Answer 10

SLR of non-symptomatic leg
also known as Fajersztain (XSLR)
(+)= increased sxs in symptomatic leg
could indicate nerve root irritation (disc herniation, encroachment by osteophytes)

Question 11

motor testing for:
iliopsoas
quads
tibialis anterior (dorsiflexion)
peroneus longus and brevis (eversion)
extensor hallucis longus
gastrocnemius/soleus (plantar flexion)
flexor hallucis longus

Answer 11

iliopsoas: L1/L2
quads: L3
tibialis anterior (dorsiflexion): L4
peroneus longus and brevis (eversion): L5
extensor hallucis longus: L5
gastrocnemius/soleus(plantar flexion): S1
flexor hallucis longus: S1

Question 12

reflex testing:
patella
medial hamstrings
achilles

Answer 12

patella: L4
medial hamstrings: L5
achilles: S1

Question 13

sensory testing: name for L1-S2 where you would apply a sensation

Answer 13

L1/L2 are high up on hip
L3 is mid thigh
L4 is medial side of calf
L5 is lateral side of calf or b/w 1st and second toes
S1 is lateral side of foot
S1/S2 are too hard to discern

Question 14

Diagnostic cluster for lumbar stenosis (5)

Answer 14

>48 yo
pain relieved by sitting
pain worsened by standing or walking
leg pain more than back pain
BL sxs

Question 15

Diagnostic cluster for cauda equina (6)

Answer 15

urinary retention
sacral sensation loss
anal sphincter tone loss 
lower extremity weakness or loss of gait
rapid onset of sxs 
hx of back pain

Question 16

Diagnostic cluster for lumbar radiculopathy (8)

Answer 16

dermatomal pattern
pain on cough, sneezing or straining
more pain sitting
subjective muscle weakness
subjective sensory loss
paresis/motor loss
\+SLR
unilateral ankle reflex

Question 17

Diagnostic cluster for lumbar compression fracture (4)

Answer 17

age > 50
age >70
trauma (adequate trauma, can be minor in elderly)
corticosteroid use

Question 18

Diagnostic cluster for spine CA (7 and combo)

Answer 18

> 50 yo
previous hx of CA
failure to improve in 1 mo of tx
no relief w/bed rest
duration of pain > 1 mo
COMBO: age > 50 or CA hx or unexplained wt loss or failure of conservative tx
insidious onset
constitutional sxs

Question 19

Diagnostic cluster for ankylosing spondylitis (6)

Answer 19

age of onset  younger than 40
more than 3 mos pain 
morning back stiffness
pain not relieved by supine position 
4/5 (+) 
improvement w/exercise

Question 20

On the SLR if there is a reproduction of sxs at 0-35 deg what tissue could be injured? at 35-70 deg? at > 70 deg?

Answer 20

0-35= lumbar strain, piriformis spasm or sacroiliac
35-70= disc and/or nerve root involvement
>70= sacroiliac or lumbar joint pain

Question 21

Between slump and SLR tests, which is more sensitive for assessing for a lumbar disc herniation vs which is more specific?

Answer 21

Slump test more sensitive for assessing for a lumbar disc herniation–> Slump might be a better screening tool
SLR slightly more specific for assessing for a lumbar disc herniation–> SLR might be able to better identify pts who have root compression or irritation