Lumbar Spine Pathologies

Disc-Related LBP / Disc Herniation Presentation

• LBP ± unilateral buttock/leg symptoms

• sitting or flexion may aggravate some presentations

• cough/sneeze/strain may reproduce symptoms

• onset may be obvious or seemingly innocuous

• leg symptoms may occur with nerve root involvement

• typically ages 20-60

• PA mobility may be uncomfortable

Disc-Related LBP / Disc Herniation Examination

• repeated movement testing

• centralization/peripheralization

• identify directional preference when present

• SLR/slump when neural involvement suspected

• neuro screen when radiculopathy is suspected

Radicular Pain

• abnormal neural activity from nerve root/DRG

• leg pain may occur without neurologic loss

• may be caused by disc or facet

Radiculopathy

• motor, sensory, and/or reflex deficit

• trend neurologic findings over time

• may or may not occur with radicular pain

Adherent Nerve Root Presentation

• persistent/recurrent radiating leg symptoms

• symptoms with combined spinal + limb loading

• limited tolerance to SLR/slump positions

• may coexist with radicular pain or previous radiculopathy

• typically not acute

• limited flexion and ipsilateral deviation

• pain at end range

• increased motion with repeated motions

• symptoms with contralateral side bending

• SLR (+)

• quadrant test (-)

• may have muscle guarding/TTP

• no difference between sitting, standing, walking

Adherent Nerve Root Examination

• SLR/slump reproduces familiar symptoms

• myotomes, dermatomes, reflexes likely (-)

• structural differentiation changes symptoms

• compare sides and relevant joint positions

• determine whether spinal position alters the neurodynamic response

Active Lumbar Movement-Restriction (Facet Lock) Presentation

• sudden onset with rotation, extension, or awkward movement

• localized, often unilateral LBP

• may feel "stuck" or unable to straighten

• marked guarding and restricted lumbar movement

• usually little to no distal neurologic involvement

• limited flexion or extension

Active Lumbar Movement-Restriction (Facet Lock) Examination

• observe protective posture and movement avoidance

• AROM limited by pain/guarding

• extension/rotation may reproduce familiar symptoms

• localized PA testing may reproduced symptoms

• rule out other causes of an acutely painful lumbar presentation

• quadrant (+)

• deviation into flexion with sidebending towards affected side

• PA stiffness above or below

Facet-Mediated LBP Presentation

• axial/paraspinal pain

• may be aggravated by extension and/or rotation loading

• local or referred symptoms are possible

• typically unilateral

Facet-Mediated LBP Presentation Examination

• reproduce familiar symptoms with relevant loading

• assess movement and functional response

• no single clinical test reliably identifies the facet

Pars Stress Injury / Spondylolysis Presentation

• adolescent / young athlete (wrestling, gymnastics, football, volleyball)

• repetitive extension and rotation exposure

• typically involves MOI

• focal activity-related LBP

• extension loading may reproduce symptoms

• physical tests alone do not rull in diagnosis

• doesn't appear on x-ray for 10-14 days (MRI needed for diagnosis)

• typically unilateral

Isthmic Spondylolisthesis

• younger patient

• associated with pars defect

• repetitive extension/rotation exposure

• commonly L5-S1

• increased lordosis

• palpable divot in spine

• muscle guarding with PA mobility

• TrA/multifidus activation deficits

Degenerative Spondylolisthesis

• older adult

• commonly L4-L5

• may coexist with stenosis/claudication

• increased lordosis

• palpable divot in spine

• muscle guarding with PA mobility

• TrA/multifidus activation deficits

Lumbar Spinal Stenosis / Neurogenic Claudication Typical Patient

• usually older adult (60+)

• degenerative changes common

• may coexist with degenerative spondylolisthesis

Lumbar Spinal Stenosis / Neurogenic Claudication Presentation

• bilateral (central foramen) or unilateral (IV formamen) presentation

• leg symptoms > back symptoms

• buttock/thigh/leg pain, heaviness, paresthesia, or weakness

• worse with standing and walking

• better with sitting, flexion - "shopping cart" sign

• walking tolerance often limited

• limited extension

• extension, ipsilateral sidebending bring on symptoms

• may have flexed posture

Lumbar Spinal Stenosis / Neurogenic Claudication Examination

• walking/standing reproduce familiar symptoms

• flexion/sitting often relieves symptoms

• lumbar extension may reproduce symptoms

• neuro exam may be (-) at rest

• differentiate between neurogenic vs. vascular claudication

• slump/SLR (-)

• may have core weakness

• quadrant test (+)

Lumbar Movement-Control / Hypermobility Typical Patient

• often younger (< 40 years)

• female

• frequently active/athletic

• may have greater generalized mobility

• often reports previous LBP episode or injury

• recurrence may follow increased or novel activity

• increase in activity or new activity

• may be able to crack back on demand

Lumbar Movement-Control / Hypermobility Clinical Pattern

• localized/recurrent LBP

• painful arc with lumbar ROM

• aberrant movement from flexion

• may demonstrate Gower's sign

• sitting, standing, walking often tolerated short-term

• symptoms/guarding may increase with activity

• prone instability test (+)

• may have crease in low back

Lumbar Movement-Control / Hypermobility Examination

• observe flexion and return from flexion

• prone instability test

• PA testing may suggest increased mobility

• assess trunk control during functional loading

• look for meaningful adjacent mobility restrictions

• core assessment

• TrA/multifidus activation

• might have tight hip flexors, lengthened hamstrings

• SLR may be > 90°

• ↑ tone / muscle guarding with PA mobility

Degenerative Lumbar Presentations

• disc degeneration / spondylosis

• facet arthroplasty

• degenerative spondylolisthesis

• some improvement with repeated movements

• limited in multiple ranges

• heat improves pain

• limited PA mobility

Lumbar Overuse / Soft Tissue Presentation (Lower Cross Syndrome) Presentation

• gradual onset with repetitive loading / inadequate recovery

• deconditioning or working beyond current capacity

• movement patterns may repeatedly overload sensitive tissues

• muscle strain may occur suddenly on a background of overuse

• typically bilateral

• diffuse or localized LBP

• usually little or no distal radiation

• muscle guarding / splinting may be prominent

• symptoms may increase with extension or prolonged activity

• walking may be less tolerated; sitting may provide relief

• ↑ lordosis - tight hip flexors, lengthened abdominals, hypertonic paraspinals

• may have core weakness

• muscle guarding with PA mobility

• may be TTP

Lumbar Overuse / Soft Tissue Presentation (Lower Cross Syndrome) Examination

• reproduce familiar symptoms with relevant loading

• assess trunk/hip strength and endurance

• observe movement quality and control

• assess soft tissue sensitivity without over-interpreting trigger points

• recheck joint mobility as guarding decreases