diagnosing lumbar conditions in primary care

Diagnosing Lumbar Conditions in Primary Care

Michael BryantBrizbrain & Spine

? Dermatome

? Myotomes

Lumbar Assessment

• Can take as little as 3 minutes• Time poor– 10 minutes per patient• History• Management plan• Where does examination fit in ?

History

• Many diagnoses are able to be established with history alone

• Often exam can tailored looking for specific findings I expect to see

• 80% of diagnoses from history alone

• Roughly 35% of lumbar problems at L4/5 and 25% of problems at L5S1

L4/5 disc

• L5 nerve – Buttock pain– Pain or sensory changes• lateral thigh• Lateral calf• Dorsum of foot

– Non specific clues• Occasionally difficulties up stairs• Stubbing toes

L5S1 Disc

• Pain or sensory changes– Posterior thigh– Posterior calf– Sole of foot

L3 and L4 Nerves

• 30% of presentations• Pains or sensory changes– Lateral to anterior thigh to knee (L3)– Lateral to anterior thigh to knee

then beyond to medial calf

• Nonspecific history– leg collapsing (quadriceps)

L1 and L2 Nerves

• 5-10% of lumbar spine problems

• Groin pains (L1)• Anterior Thigh pains (L2)

Examination

L2

• Hip flexors• Pain/sensory changes in the anterior

thigh

L3

• Knee extensor weakness• Reduced knee jerk• Pain/sensory changes anterior thigh to

knee

L4

• Ankle dorsiflexion weakness• (Possible) Reduced knee jerk• Pain/Sensory changes anterolateral

thigh and medial calf

L5

• Great toe dorsiflexion wekaness– Ankle dorsiflexion weakness

• Pain/sensory changes buttock/lateral thigh/lateral calf/top of foot

S1

• Ankle plantar flexion weakness• Pain/Sensory changes posterior

thigh/calf and sole/lateral aspect of the foot

• Reduced ankle jerk

Facet Pain

• Pain in extension and rotation

Other Findings

• Spinal cord issues– Brisk reflexes across the groups– Extensor plantar response– Go looking for sensory levels

Other Findings

• Cortical Problems– Weakness or sensory changes across

multiple dermatomes/myotomes– Often matching upper limb changes

Questions