Updated: 6/27/2021

Lower Extremity Spine & Neuro Exam

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  • Overview
    • Note: The table below is a simplification as muscles are often innervated by multiple nerve root
      • for example, ankle dorsiflexion usually has a contribution from both L4 and L5
      • Lower Extremity Spine and Neuro Exam
      • Nerve root
      • Primary Motion
      • Primary muscles 
      • Sensory
      • Reflex
      • L1
      • Iliac crest and groin
      • Cremasteric reflex (L1 and L2)
      • L2
      • Hip flexion and adduction
      • Iliopsoas (lumbar plexus, femoral n.)
      • Hip adductors (obturator n.)
      • Anterior and inner thigh
      • Cremasteric reflex (L1 and L2)
      • L3
      • Knee extension (also L4)
      • Quadriceps (femoral n.)
      • Anterior thigh, medial thigh and medial knee
      • -
      • L4
      • Ankle dorsiflexion (also L5)
      • Tibialis anterior (deep peroneal n.)
      • Lateral thigh, anterior knee, and medial leg
      • Patellar
      • L5
      • Foot inversion
      • Toe dorsiflexion
      • Hip Extension
      • Hip abduction
      • Tibialis posterior (tibial n.)
      • EHL (DPN), EDL (DPN)
      • Hamstrings (tibial) & gluteus max (inf. gluteal n.)
      • Gluteus medius (sup. gluteal n.)
      • Lateral leg & dorsal foot
      • -
      • S1
      • Foot plantar flexion
      • Foot eversion
      • Gastroc-soleus (tibial n.)
      • Peroneals (SPN)
      • Posterior leg
      • Achilles
      • S2
      • Toe plantarflexion
      • FHL (tibial n.), FDL (tibial)
      • Plantar foot
      • -
      • S3 & S4
      • Bowel & bladder function
      • Bladder
      • Perianal
      • -
  • History & Symptoms
      • Characteristic symptoms
      • Systemic symptoms (weight loss)
      • Tumor, infection
      • Evaluation of localized axial pain
      • Tumor, infection
      • Mechanical pain
      • Instability, discogenic pain
      • Radicular pain
      • HNP
      • Night pain
      • Tumor
      • Referred pain
      • Peptic ulcer disease, cholecystiits, nephrolithiasis, PID, pancreatitis
      • Concomitant pain
      • Hip & shoulder
      • Psychogenic
      • Secondary gain
    • Inspection
      • skin
        • looking for prior scars, cafe au lait spots, hairy patches in the lower lubmar spine
  • Motor Exam
      • Muscle Grading System (ASIA)
      • 0
      • Total paralysis
      • 1
      • Palpable or visible contraction
      • 2
      • Active movement, full range of motion, gravity eliminated
      • 3
      • Active movement, full range of motion, against gravity
      • 4
      • Active movement, full range of motion, against gravity and provides some resistance
      • 5
      • Active movement, full range of motion, against gravity and provides normal resistance
      • NT
      • Patient unable to reliably exert effort or muscle unavailable for testing due to factors such as immobilization, pain on effort, or contracture.
  • Sensory Exam
      • Sensory Grading System (ASIA)
      • 0
      • Absent
      • 1
      • Impaired
      • 2
      • Normal
      • NT
      • Not Testable
  • Specific Tests
    • Special tests
      • straight leg raise
        • compression of lower lumbar nerve roots (L4-S1)
        • important to distinguish from hamstring tightness
        • considered positive if symptoms produced with leg raised to 40°
      • crossed straight leg raise
        • performing straight leg raise in uninvolved leg produces symptoms in involved leg
      • Babinski's test
        • positive findings suggests upper motor neuron lesion
      • ankle clonus test
        • associated with upper motor neuron lesion
      • bulbocavernous reflex
        • tests for the presence of spinal shock
        • positive reflex with anal sphincter contraction with squeezing of glans penis or clitorus
          • can alternatively tug on foley catheter to stimulate reflex
    • Lumbosacral plexus illustration
    • Sensory illustration
  • Clinical Findings
      • Clinical Findings
      • Symptoms
      • Neurologic etiology
      • Causes
      • Paresthesias alone medial aspect of knee
      • Irritation of saphenous division of femoral nerve
      • Psoas abscess
      • Saphenous n. compression (surfing)
      • A Trendelenburg gait
      • Injury to L5 nerve root
      • Paracentral L4/5 HNP
      • Numbness along lateral thigh
      • Meralgia paresthetica (lateral femoral cutaneous nerve palsy)
      • Compression of LFCN (patient positioning)
      • Foot drop
      • Common peroneal nerve palsy or sciatic nerve compression
      • Lateral knee compression
      • Hip dislocation
      • Quadriceps weakness
      • Femoral nerve palsy
      • Hyperflexed Pavlik harness
      • L3 and L4 nerve root compression
  • Waddel Signs
    • Waddell identified 5 exam findings that correlated with non-organic low back pain. The tests include
      • Waddell Signs
      • Finding
      • Description
      • 1. Tenderness
      • a. Superficial - pain with light touch to skin
      • b. Deep - nonanatomic widespread deep pain
      • 2. Simulation
      • a. Pain with light axial compression on skull
      • b. Pain with light twisting of pelvis
      • 3. Distraction
      • No pain with distracted SLR
      • 4. Regional
      • a. Nonanatomic or inconsistent motor findings during entire exam
      • b. Nonanatomic or inconsistent sensory findings during entire exam
      • 5.Overreaction
      • Overreaction noted at any time during exam

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Questions (2)

(OBQ13.22) A Trendelenburg gait would most likely be caused by which of the following lumbar conditions.

QID: 4657

L3/4 far lateral disc herniation

22%

(1315/5851)

L3/4 central disc herniation with impingement on the bilateral descending nerve roots

3%

(186/5851)

L4/5 far lateral disc herniation

14%

(841/5851)

L5/S1 far lateral disc herniation

54%

(3171/5851)

L5/S1 paracentral disc herniation

5%

(315/5851)

L 1 B

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