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Several physical findings should be sought because they help identify those few patients who need more than conservative management Neurologic examination of the lower extremities will detect the small deficits produced by disk disease and the large deficits complicating such problems as cauda equina tumors A positive straight leg raising test indicates nerve root irritation The examiner performs the test on the supine patient by passively raising the patient s ipsilateral leg The test is positive if radicular pain is produced with the leg raised 60 degrees or less It has a specificity of 40% but is 95% sensitive in patients with herniation at the L4 5 or L5 S1 level (the sites of 95% of disk herniations) It can be falsely negative, especially in patients with herniation above the L4 5 level The crossed straight leg sign is positive when raising the contralateral leg reproduces the sciatica It has a sensitivity of 25% but is 90% specific for disk herniation Detailed examination of the sacral and lumbar nerve roots, especially L5 and S1, is essential for detecting neurologic deficits associated with back pain Disk herniation produces deficits predictable for the site involved (Table 20 6) Deficits of mul-



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Low back pain is a final common pathway of many processes; the pain of vertebral osteomyelitis, for example, is not very different in quality and intensity from that due to back strain of the weekend gardener Historical factors of importance include smoking, weight loss, age over 50, and cancer, all of which are risk factors for vertebral body metastasis Osteomyelitis most frequently occurs in adults with a history of recurrent urinary tract infections and is especially common in diabetics and injection drug users A history of a cardiac murmur should raise concern about endocarditis, since back pain is not an uncommon manifestation A background of renal stones might indicate another cause of referred back pain

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Certain qualities of a patient s pain can indicate a specific diagnosis Low back pain radiating down the buttock and

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Nerve Root L4 L5 S1 Motor Dorsiflexion of foot Dorsiflexion of great toe Eversion of foot Reflex Knee jerk None Ankle jerk Sensory Area Medial calf Medial forefoot Lateral foot

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tiple nerve roots suggest a cauda equina tumor or an epidural abscess, both requiring urgent evaluation and treatment Measurement of spinal motion in the patient with acute pain is rarely of diagnostic utility and usually simply confirms that pain limits motion An exception is the decreased range of motion in multiple regions of the spine (cervical, thoracic, and lumbar) in a diffuse spinal disease such as ankylosing spondylitis By the time the patient has such limits, however, the diagnosis is usually straightforward If back pain is not severe and does not itself limit motion, the modified Schober s test of lumbar motion is helpful in early diagnosis of ankylosing spondylitis To perform this test, two marks are made, one 10 cm above S1 and another 5 cm below The patient then bends forward as far as possible, and the distance between the points is measured Normally, the distance increases at least 5 cm Anything less indicates reduced lumbar motion, which in the absence of severe pain is most commonly due to ankylosing spondylitis or other seronegative spondyloarthropathies Palpation of the spine usually does not yield diagnostic information Point tenderness over a vertebral body is reported to suggest osteomyelitis, but this association is uncommon A step-off noted between the spinous process of adjacent vertebral bodies may indicate spondylolisthesis, but the sensitivity of this finding is extremely low Tenderness of the soft tissues overlying the greater trochanter of the hip is a manifestation of trochanteric bursitis Inspection of the spine is not often of value in identifying serious causes of low back pain The classic posture of ankylosing spondylitis is a late finding Scoliosis of mild degree is not associated with an increased risk of clinical back disease Cutaneous neurofibromas can identify the rare patient with nerve root encasement Examination of the hips should be part of the complete examination While hip arthritis usually produces groin pain, some patients have buttock or low back symptoms.

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Extracting Text From A PDF Using Only Javascript - HubLog
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