Overview of Lumbar Spine Assessment

Original Editor - Shala Cunningham Top Contributors - Jess Bell and Stacy Schiurring

Introduction

Low back pain is the leading cause of disability in most countries, with a point prevalence of 11.9%. Years lived with disability caused by low back pain are continuing to increase, and the socioeconomic burden of low back pain is high. Around half of all individuals with low back pain seek care, and it is estimated that around 60 percent of patients presenting to a primary care physician have a complaint of low back pain. It is, therefore, important that rehabilitation providers have a comprehensive understanding of the lumbar spine evaluation. This page provides an overview of this evaluation and includes links for more information.

History

When assessing patients with low back pain, age can help us formulate hypothetical diagnoses about the potential pathoanatomical cause of pain:

• individuals aged less than 20 years old: low back pain is rare (apart from muscle sprains), so check for anomalies (e.g. spondylolisthesis / step-off)
• individuals aged between 20 and 50 years: more likely a disc pathology, muscle strain or instability
• individuals aged more than 50 years: more likely associated with degeneration, so consider conditions such as arthritis or spondylosis
  • please note that there is a "fuzzy" period between the ages of 45 and 60 years, where back pain could be related to disc pathology or degeneration

The mnemonic L-M-N-O-P-Q-R-S-T is used to cover the key aspects you should consider when taking a patient’s history.

L: location of symptoms and level of functional impairment

We want to know the exact location of pain - is it general or localised? Does it radiate or move? It is important to fill in a body chart to determine exactly where a patient does and does NOT have symptoms.

M: medical factors (medications) and mechanism of injury

We need to find out what medications the patient is taking (including those prescribed by physicians or other healthcare providers or supplements) and what co-morbidities they may have.

We also want to determine when and how the injury occurred. For low back pain, consider the following questions:

• Was the patient lifting something?
• Did they fall?
• What happened when they first noticed their low back pain?
• If they have experienced a traumatic injury (e.g. a fall / motor vehicle accident), do they have any neurological symptoms?

Red flags: no incident / accident with sudden onset of severe pain AND neurological symptoms following a trauma

N: neurological symptoms

Neurological symptoms include numbness, tingling, burning, and electrifying pain. When neurological symptoms are present, we need to determine if they are constant or intermittent and if they follow a dermatomal or a peripheral nerve pattern. Consider also if symptoms are related to the position of the patient’s back (i.e. certain activities make certain symptoms worse).

Subjective red flag symptoms related to cauda equina are loss of sensation in the saddle / perineal region (saddle anaesthesia), urinary retention/overflow incontinence and faecal incontinence.

O: occupation, including limitations

Are there any work- or activity-related factors that are relevant?

P: palliating and provocating symptoms

Find out from the patient exactly what makes their symptoms better or worse. It is important to ask how long it takes for symptoms to calm down once they are irritated / increased.

Red flag symptom: symptoms that are constant and unrelenting.

Q: quality of symptoms/pain

For the low back, consider if there is numbness, tingling, unusual sensations (e.g. ants crawling on skin) etc.

R: radiation of symptoms

Questions to consider for radiating symptoms are:

• Where do the symptoms radiate to?
• Are radiating symptoms provoked by activities or position?
• How long do symptoms last?

Red flag symptom: radiating symptoms down multiple dermatomes (ruling out peripheral nerve distributions first).

S: severity of symptoms

It can be helpful to use scales such as the Visual Analogue Scale or the Numeric Pain Rating Scale, but also consider how symptoms affect function and activities.

Red flag symptom: sudden onset of severe pain without incident or accident.

T: timing of symptoms

Consider the sequence of symptoms and the progression of symptoms throughout the day.

Red flag symptom: pain that interrupts sleep or is worse at night (this pain isn’t related to sleeping position) OR constant pain

Red Flags Specific to Low Back Pain

Despite a lack of consensus, red flags are still considered the most reliable clinical indicator of potentially serious pathology. In the lumbar spine, we use red flags to help detect pathologies such as fracture, infection and cancer. Common red flags in the back are:

• aged over 50 years
• history of trauma
• immunosuppression
• night pain / pain at rest
• lower extremity neurological deficits
• history of cancer
• saddle anaesthesia
• bladder / bowel dysfunction
• fever / chills
• night sweats
• weight loss
• recent infection

Self-Assessment Questionnaires for Low Back Pain

• Oswestry Disability Index / Modified Oswestry Disability Questionnaire
• Roland-Morris Disability Questionnaire
• Patient Specific Functional Scale
• Fear Avoidance Belief Questionnaire
• Pain Catastrophizing Scale

Objective Assessment

Observation

You can start observing a patient from when you first see them in the waiting room or treatment area. Consider the following:

• how did they come into the treatment area (if applicable)
• is the patient seated, or do they prefer to stand?
• is the patient sitting asymmetrically?
• do they have a lateral shift?

Posture Assessment

We want to assess posture in sitting and standing. A full postural assessment is discussed here. Specifically for the lumbar spine, you will look at the following:

• general spinal curvature:
  • assessed from behind
  • look for scoliosis or lateral shift

• lumbar spine:
  • assessed from the side - is there an increased lumbar lordosis or a flattened lumbar spine?
  • assessed from the back - is there any visible muscle spasm? Or is there hinging at the thoracolumbar junction?
• pelvis
  • assessed from the front, rear and side
  • assess levels of anterior superior iliac spine (ASIS) and posterior superior iliac spine (PSIS)
  • assess levels of the iliac crests
  • is pelvis in an anterior or posterior tilt?
• hips
  • symmetry - are the hips level?
  • are the hips in internal or external rotation?
  • is there a visible gluteal bulk?
  • when viewed from the side, are the hips in extension or flexion?

Other elements to assess in a full postural assessment include:

• head on neck position
• shoulder position
• thoracic spine (increased / decreased kyphosis
• knees (is there any hyperextension?)

To learn more, please see: Posture and Sports Screening: Postural Assessment.

Gait Assessment

We need to determine if there are any neurological impairments, such as foot drop, ataxia, lack of weight shift or leaning to one side.

A full gait assessment is discussed here. During a gait assessment, you can look at temporal variables, such as stride time and step time, and distance variables, such as stride length, step length and step width. Other variables include cadence and gait speed / velocity.

Functional Screen

During a functional screen, it is useful to assess:

• forward bend or trunk flexion
• backward bend or trunk extension
• rotation
• squatting

You will need to first determine if these tests are appropriate for your patient (consider irritability, balance limitations).

Neurological Testing

The full neurological screen is discussed here, but it includes myotome testing, sensory testing, reflex testing and neurodynamic tests.

Myotome Testing

Myotomes represent a group of muscles that are innervated by a single nerve root. We assess myotomes using manual muscle testing - this involves the sustained isometric contraction of a specific group of muscles (see Table 1).

Table 1. Lower extremity myotomes

Nerve Root	Lower Extremity Movement
L2	Hip flexion
L3	Knee extension
L4	Ankle dorisiflexion
L5	Big toe extension
S1	Ankle plantarflexion
S2	Knee flexion

Assessing myotomes can be supplemented by a functional assessment. Relevant functional strength tests include:

• heel walking
• toe walking
• single-leg heel raises
• single-leg squats

Sensory testing

Light touch is typically used for sensory testing. You can use your fingertips or a cotton swap to apply light touch to a dermatome. It’s important to test each side and compare if it feels the same. There are a number of dermatomal maps. However, these maps vary significantly, and even among individuals, there is often overlap between dermatomes. For consistency, ensure you use the same map with each patient. See Table 2 for a list of the lower limb dermatomes.

Table 2. Lower extremity dermatomes

Dermatome	Area
L1	Greater trochanter
L2	Front of thigh to knee
L3	Anterior thigh and knee, medial lower leg
L4	Lateral thigh, medial leg, dorsum of foot, big toe
L5	Posterior and lateral thigh, lateral aspect of leg, dorsum of foot, medial half of bottom of foot, toes 1-3
S1	Posterior thigh

Reflex Testing

A reflex occurs automatically, without conscious thought. It involves the involuntary movement of an organ / body part in response to a stimulus (e.g. a reflex hammer in deep tendon reflex testing).

Deep Tendon Reflexes

For patients with low back pain, the patellar and Achilles tendon reflexes are most often assessed.

Table 3. Lower limb reflexes

Reflex	Nerve Supply	Segmental Innervation	Area to Test	Expected Response
Patellar	Femoral nerve	L2-L4	Patella tendon	Knee jerk / knee extension
Achilles	Tibial nerve	S1-2	Achilles tendon	Plantarflexion

Pathological reflexes

Table 4 details which pathological reflexes may be included in a lumbar spine evaluation.

Table 4. Pathological reflexes

Reflex	Description of Action	Abnormal response
Babinski Sign	Stroke the plantar surface of the foot from heel to great toe, starting from the lateral side and sweeping across to the medial side at the ball of the foot.	Extension of the great toe and fanning out of the other toes.
Clonus Reflex	Forcibly and quickly dorsiflex the foot while holding up the leg under the popliteal space.	More than three involuntary beats or continued rapid flexion and extension of the foot.
Oppenheim Test	The patient is positioned in sitting or supine, and the examiner grasps the lower leg with one hand. Using either the opposite end of a reflex hammer or thumbnail, the examiner quickly runs the point of stimulation along the crest of the patient's tibia in a downward motion.	Great toe extension and fanning out of the other toes.

Neurodynamic Testing

Neurodynamic tests are often used in patients who have suspected entrapment neuropathies. The following tests are used when assessing the lumbar spine:

• straight leg raise
  • symptoms below around 35 degrees can be related to disc herniation
  • symptoms between 35-75 degrees could be sciatic nerve tension
  • symptoms over 75 degrees are likely related to hamstring stretch
• slump test
  • helps to distinguish between hamstring stretch and sciatic nerve tension
• femoral nerve tension test (performed in prone or side lying if unable to get into prone)

Likelihood ratios

Lauder et al. looked at likelihood ratios for a cluster of four abnormal tests as a predictor of lumbosacral radiculopathy: altered reflexes, weakness, altered sensation and a positive straight leg raise. They found the following:

• if all four of these tests are abnormal, there is a positive likelihood ratio (+LR) of 6.0 and a negative likelihood ratio (-LR) of 0.95
• if three tests are abnormal, there is a +LR of 4.0 and a  -LR of 0.91
• if only one test is positive, there is a +LR of 1.34 and a -LR of 0.37

Palpation

In standing, palpate to check the alignment of the spinous processes, looking for scoliosis or step-offs associated with spondylolisthesis. Also, compare the height of the iliac crests, posterior superior iliac spines (PSIS) and gluteal folds. They should be symmetrical across and relatively aligned.

You can also palpate in sitting to see if the patient's posture changes between a seated and a standing position. In sitting, you can also palpate the musculature (quadratus lumborum, paraspinals / erector spinae) to check for tenderness and muscle guarding.

Range of Motion

Assess the following movements in standing:

• flexion
• extension
• rotation
• side bend
• quadrant (or Kemp) test and combined movements (extension, side bend, rotation and flexion, side bend and rotation)
• hip range of motion

Please note that if patients have a balance deficit or substitution through their hips, you may need to test their range of motion in sitting.

Repeated Movement Testing

You might also include repeated movement testing in your evaluation. Ask the patient to do up to ten repetitions of:

• flexion
• extension
• side glides if a lateral shift is present

During repeated movement testing, you are looking for changes in symptoms, particularly radiating symptoms. Does the movement cause pain to centralise (i.e. become more proximal) or peripheralise (i.e. spread distally)?

Muscle Testing

Multifidi: Individuals with low back pain that is associated with degenerative conditions have increased fatty infiltration and atrophy compared to age-matched controls, so it is important to assess and strengthen these muscles:

• aim to achieve “swelling” of multifidi (see video below)
• weight shifts or arm lifts also activate the multifidi

Transversus abdominis: the "proper functioning" of transversus abdominis is an important aspect in the rehabilitation of low back pain. These muscles can be activated by practising the drawing in manoeuvre (see video below).

Myotomal testing: should be completed during muscle testing, if it has not previously been assessed as part of the neurological screen.

Passive Physiological Intervertebral Motion Testing (PPIVM)

Tested in side-lying:

• segmental movement into flexion
• segmental movement into extension
• segmental movement into rotation

Look for movements that are hypomobile, normal, or hypermobile.

Passive Accessory Intervertebral Motion (PAIVM)

Tested in prone:

• posterior to anterior glides (PAs)
• unilateral posterior to anterior glides (UPAs)

Special Tests

Prone Instability Test

The prone instability test is designed to identify individuals with low back pain who may benefit from trunk stabilisation exercises.

Please note that this test can be quite difficult to perform, so it won’t be suitable for all patients:

• patient lies prone over the end of the table with their feet resting on the floor
• the therapist provides a posterior to anterior pressure to the lumbar spine at each level looking for provocation of pain
• the patient is cued to lift their legs off the floor
• while the legs are lifted, the therapist again provides posterior to anterior pressure to the lumbar spine at each level looking for provocation of pain
• positive test = pain is reduced in the second movement