Overview Note: The table below is a simplification as muscles are often innervated by multiple nerve roots for example, ankle dorsiflexion usually has contributions from both L4 and L5 Lower Extremity Spine and Neurologic 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 nerve) Hip adductors (obturator nerve) Anterior and inner thigh Cremasteric reflex (L1 and L2) L3 Knee extension (also L4) Quadriceps (femoral nerve) Anterior thigh, medial thigh, and medial knee - L4 Ankle dorsiflexion (also L5) Tibialis anterior (deep peroneal nerve) Lateral thigh, anterior knee, and medial leg Patellar L5 Foot inversion Toe dorsiflexion Hip extension Hip abduction Tibialis posterior (tibial nerve) EHL (DPN), EDL (DPN) Hamstrings (tibial nerve), gluteus maximus (inferior gluteal nerve) Gluteus medius (superior gluteal nerve) Lateral leg and dorsal foot - S1 Foot plantar flexion Foot eversion Gastrocsoleus (tibial nerve) Peroneals (SPN) Posterior leg Achilles S2 Toe plantar flexion FHL (tibial nerve), FDL (tibial nerve) 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, cholecystitis, nephrolithiasis, PID, pancreatitis Concomitant pain Hip & shoulder Psychogenic Secondary gain Inspection skin looking for prior scars, café au lait spots, hairy patches in the lower lumbar 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 suggest upper motor neuron lesion ankle clonus test associated with upper motor neuron lesion bulbocavernosus reflex tests for the presence of spinal shock positive reflex with anal sphincter contraction with squeezing of glans penis or clitoris can alternatively tug on foley catheter to stimulate reflex Lumbosacral plexus illustration Sensory illustration Clinical Findings Clinical Findings Symptoms Neurologic Etiology Causes Paresthesias along medial aspect of knee Irritation of saphenous division of femoral nerve Psoas abscess Saphenous nerve compression (surfing) Trendelenburg gait Injury to L5 nerve root Paracentral L4/5 HNP Numbness along lateral thigh Meralgia paresthetica (lateral femoral cutaneous nerve (LFCN) 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 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