CASE#4

GROUP 1
SECTION C
Members

CASE #4
Deep Back
A 55 y/o male came in with a chief complaint of dull,
aching pain at the low back associated with radiating
pain towards the lateral aspect of the left leg and foot.
MRI of the lumbosacral region reveals a Herniated
Nucleus Pulposus on the level of L5-S1. The patient
works as a laborer and states that symptoms are being
experienced for 3 months already and medications do
not offer relief of symptoms. Pt also noted that pain
increases with trunk flexion, heavy lifting, twisting,
prolonged standing, and sitting but is relieved by any
extension maneuvers.

Discuss the anatomy of the deep

back:
Structures probably affected
Vertebral Column
Anterior Portion: Provides for
weight bearing, shock absorption,
and mobility in all direction
Posterior Portion: protection of the
spinal cord, guidance and limitation
of motion, and elongated processes
to increase the leverage of muscles
of the trunk and leverage

Discuss the anatomy of the deep

back:
Structures probably affected
Ligaments
Anterior Longitudinal Ligament
Posterior Longitudinal Ligament
Ligamentum Flava
Interspinous Ligament
Supraspinous Ligament

Invertebral Disc
Annulus Fibrosus: Colaginous,
absorb and distribute forces and
limit motion
Nucleus Pulposus: water, permits
one vertebra to rock anteriorly or
posteriorly on another

Discuss the anatomy of the deep

back:
Structures probably affected
Typical Lumbar Vertebrae:

Body: Large kidney shaped

Vertebral foramen: Small & triangular
Transvers process: Long & slender
Articular processes: sup & med; inferior &
lat
No articulation facets in the ribs

Sacrum:

Fused together
Concave anteriorly
Sacral Hiatus
Sacral Foramina where anterior and
posterior sacral rami nerve passes

Discuss the anatomy of the deep

back:
Structures probably affected

Possible cause of the radiating pain

towards the lateral aspect of the leg
Impingement of sensory
posterior roots on the L5
and S1 because of
Herniated Nucleus Pulposus
When the posterior part of
the annulus fibrosus
ruptures, and the nucleus
pulposus is forced posteriorly.

Possible cause of the radiating pain

towards the lateral aspect of the leg

Possible cause of the radiating pain

towards the lateral aspect of the leg

Muscles that would most likely have

weakness
Root
Injury

Dermatome Pain

Muscle Supplied

Movement Weakness

L5

Lateral part of the

lower leg and dorsum
of the foot

Extensor halluces
longus, Extensor
digitorum longus

Toe extension, ankle

dorsiflexion

S1

Lateral edge of pain

Gastrocnemius and
Soleus

Ankle plantar Flexion

ROM for Lumbosacral region

LUMBAR FLEXION:MODIFIED SCHOBER TEST

Procedure :

1. Place the rst mark at the lumbosacral junction with a skin marking pencil. Place
a second mark 10 cm above the rst mark. Place a third mark 5 cm below the rst
mark at the lumbosacral junction.
2. Align the tape measure between the most superior and the most inferior marks.
Ask the subject to bend forward as far as possible while keeping the knees straight.
3. Maintain the tape measure against the subjects back during the movement, and
note the distance between the most superior and the most inferior marks at the end
of the ROM. The ROM is the difference between 15 cm and the length measured at
the end of the motion.

ROM for Lumbosacral region

LUMBAR EXTENSION: MODIFIED SCHOBER TEST
Procedure:
1. Use a skin-marking pencil to place a rst mark at the lumbosacral junction. Place
a second mark 10 cm above the rst mark. Place a third mark 5 cm below the rst
mark (lumbosacral junction).
2. Align the tape measure between the most superior and the most inferior marks.
3. Ask the subject to put the hands on the buttocks and to bend backward as far as
possible.
4. Note the distance between the most superior and the most inferior marks at the
end of the ROM, and subtract the final measurement from the initial 15 cm. The ROM
is the difference between 15 cm and the length measured at the end of the motion

Special Tests
STRAIGHT LEG RAISING TEST
A passive test, and each leg is tested
individually with the normal leg being tested
first
1. Pt in SUPINE position
2. Hip medially rotated and Adducted and
Knee Extended
3. The examiner Flexes the Hip until the Pt
complains of pain or tightness in the back or
back of the leg
If the pain is primarily back pain, it is more
likely a Disc Herniation from Pressure on the
Anterior Theca of the Spinal Cord, or the
pathology causing the pressure is more
central

Special Tests
COMPRESSION TEST
1. Pt lies SUPINE with the Hips and Knees Flexed
2. Hips are Flexed until the PSISs start to move
backward (usually about 1000 Hip Flexion)
3. Examiner then applies direct pressure against
the Pts feet or buttocks applying axial
compression to the spine
Radicular pain into the Posterior Leg is produced
POSITIVE for a possible Disc Herniation