Case Scenario • Mr B is a 45 year old teacher. He has this low back pain for 3 weeks and the pain came on when he was playing basketball. In the past 2 weeks he has noticed a sharp pain down the back of his right leg which goes right down to his ankle and worse on coughing or sneezing. He has no bladder or bowel disturbance
Approach • Rapport • Site of pain • Seek permission to conduct examination + undress appropriately down to underwear • Patient standing: inspection • Patient supine: SLR (Lasague’s sign + Kernig’s sign) • Tests of peripheral nerve function lower limbs • Patient prone: tenderness including sacro-iliac joints • Patient sitting down: Slump test
Surface anatomy landmarks: IS LT 12, 10? (1) Iliac crests (IC), posterior (2) Superior iliac spines (PSIS). Spinous process of L4 lumbar vertebra lies at or just below the level of the iliac crest. (3) Lumbosacral junction (=) lies 10–15° superiorly and toward the midline from the PSISs. (4) T12 can be located by counting spinous processes back from the lumbosacral junction. (5) T10 is at a line drawn along the 12th rib and continued to the midline to meet its contralateral fellow
History back pain (1) Circumstances associated with pain onset (2) Primary site of pain (3) Radiation of pain (4) Character of pain (eg. is pain throbbing, sharp, aching) (5) Intensity of pain (eg. on visual analogue scale)– at rest – on movement– at present– during past week– highest level (6) Factors altering pain– what makes it worse?– what makes it better? (7) Associated symptoms (eg. nausea) (8) Temporal factors– is pain present continuously or otherwise? (9) Effect of pain on activities (10) Effect of pain on sleep (11) Medications taken for pain Other treatments used for pain (12) Health professionals consulted for pain
Functional tests • Gait • Moaning and groaning of the back
Inspection + palpation • Observe patient standing front, back + sides for BAGS • Body habitus • Asymmetry of posture, • Gait • Spinal curves, or muscle bulk, or • Skin abnormalities • The level of the iliac crests assessed + note any asymmetry,indicating LPSH • leg length inequality • a pelvic rotation • a thoraco-lumbar scoliosis or • inequality size of the hemipelvis.
Tips on examination • Deviation to one side during flexion or extension said to be (but has not been proven) a sign of • either subtle lumbosacral instability or • a significant disc bulge or prolapse • Flexion in standing recorded relative to finger tips reaching tibialtuberosity or malleoli+ for side bending relative to the superior or inferior pole of the patella
Movements • Flexion • Extension • Lateral flexion bilaterally • Rotation bilaterally
Tests of peripheral nerve function lower limbs • Power: walking on toes( mainly S1), walking on heels ( mainly L5) • Squatting : exacerbates pain right sacro-iliac joint • Sensation • Reflexes
Rotation The hips need to be stabilised to • Exclude motion of the pelvis, either by the examiner holding the hips, or by testing in the seated position. • If reproduction of pain has not occurred with these routine movements, then overpressure by the examiner in each plane can be used to further stress the spinal column
The Quadrant test The combined motion of extension, rotation and lateral flexion Provocative test used if pain reproduction has still not occurred
Tests done with patient seated on edge of examination couch • Straight leg raise (SLR) in sitting is tested first. • The slump test ( a sign of neuromeningeal irritation, can be added if pain reproduction has not occurred with the sitting SLR.)
Patient lying supine Part 1 (1) Leg lengths (2) The straight leg raise test, with and without dorsiflexion of the ankle,. Neck flexion in the slump test, + ankle dorsiflexion in SLR should make no difference to any back or leg pain in cases of hamstring tightness or pain, increase pain in cases of neuromeningeal irritation.
Straight leg rising tests Limitation straight leg raise: nerve root irritation • Nerve root does not move until the leg is raised 30 degrees( symptoms between 0 -30 degrees viewed with suspicion) • Nerve root irritation do not refer to back pain, referred leg pain or hamstring tightness • SLR positive : nerve root irritation of one of the nerve roots forming the sciatic nerve L4-S3(Refer pain distribution below)
Femoral nerve stretch test • Implies nerve root irritation forming the femoral nerve ( L2-4)
Patient lying supine Part 2 (3) A screening of hip motion . Restriction of hip flexion that produces discomfort in the back +/or buttock, rather than the groin, may be due to stiffness in the lumbar spine, +/or shortening of buttock muscles and not due to hip pathology. (4) Provocative tests purportedly of the sacroiliac joint function, namely the FABER and the FADLong tests
Palpation • Patient to lie prone. • A pillow placed under the abdomen is often more comfort-able + allows for maximal relaxation of lumbar paraspinal muscles. • A gentle palpatory screen undertaken to gauge the degree and location of any muscle spasm, as well as changes in skin texture. • A systematic approach to further palpation . Palpation over each of the spinous processes + unilaterally on each side is performed, looking for underlying intervertebralsegmental stiffness, tenderness and pain reproduction. • Systematic palpation of each segment from the thoracolumbar junction to the lumbosacral junction performed. • Palpation around the sacrum and buttock completes the examination. Remember low back pain can be referred from the thoracolumbar junction, + sacroiliac joint dysfunction
Red Flags (1) Recent significant trauma (2) Milder trauma if age > 50 years (3) Unexplained weight loss (4) Unexplained fever (5) Immunosuppression (6) Previous or current cancer (7) Intravenous drug use (8) Osteoporosis (9) Chronic corticosteroid use (10) Age > 70 years (11) Focal neurological deficit (12) Duration >6 weeks
Terminologies • Radicular pain involves a region beyond the spine. • Radiculopathy objective loss of sensory + /or motor function as a result of conduction block; the features of which might include numbness, motor loss, wasting, weakness, and loss of reflexes.
Causes radicular pain (1) Disc herniation (commonest cause) (2) Spinal stenosis (3) Synovial cysts (4) Infection (5) Infestation (6) Tumour (7) Vascular abnormalities
Natural history lumbar radicular pain • A dramatic reduction in the severity of pain with treatment limited to simple analgesics. • At 12 months, at least 50% of patients can expect to be free of leg pain, but at least 60–70% will continue to experience low back pain
Imaging • In the absence of other indications, imaging is not required for 4–6 weeks after the onset of LRP • Imaging is best reserved for • patients who do not respond to conservative treatment • whom surgery is contemplated. In patients with a history of • sciatica or • in whom a ‘red flag’ condition seems likely,appropriate imaging should be requested.
Treatment lumbar radicular pain 1. Bed rest no more effective than watchful waiting. Depending on the severity and response to medication, the early resumption of daily activities should be encouraged. 2. Clinical studies shown neither piroxicam nor indomethacin nor oral dexamethasone offer greater analgesia than placebo. Severe pain: opioids used judiciously. 3. Efficacy physical modalities :manipulation+ traction remains controversial, + no compelling evidence to encourage their utilisation. 4. Injection techniques such as botulinum toxin, prolotherapy, or facet joint injections are irrational+ illogical.