If the patient's complains of a radiating type pain down one leg, suggestive of nerve root irritation, proceed as follows:

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1 BACKS HISTORY, HISTORY, HISTORY Questions, questions, & more questions 1. What caused pain? 2. Repetitive, lifting, fall? 3. Acute or chronic? 4. Location? 5. Radiation? 6. Numbness? 7. Muscle weakness? 8. Does lying down relieve pain? 9. Difficulty moving? 10. What relieves it? 11. What makes it better? 12. Previous back surgeries, injection? Can the patient point to the precise area of the pain? Is it along the vertebral column? Para-spinal, as might occur with spasm? Radiating down the legs as would occur with nerve root irritation? Palpate the spine. Processes that inflame the bone (e.g. compression fracture, osteomyelitis, metastatic disease) will generate pain when the affected vertebrae is palpated or percussed. If the patient's complains of a radiating type pain down one leg, suggestive of nerve root irritation, proceed as follows: Inspect GAIT & Posture Observe for abnormal gait and posture, which may provide clues as to the nature and severity of the problem. PALPITATION Spinous process, Sacroiliac joints, Paraspinous muscles

2 INSPECTION Superficial landmarks include: T1 is the most prominent spinous process at the base of the neck. T7/T8: lower border of scapulae. L4: iliac crests. S2: dimples at posterior superior iliac spines. Lumbar lordosis Thoracic kyphosis Scoliosis Pelvic asymmetry/tilt ROM Lumbar flexion Lumbar extension Lateral bend Rotation Hip flexion (L1) Hip adduction (L2) Knee extension (L3) Ankle dorsiflexion (L4) Great-toe dorsiflexion (L5) Ankle eversion (S1) MOVEMENTS Flexion: Observe carefully, as hip flexion can account for apparent motion in a rigid spine. Flexion may be recorded by the distance between the fingers and the ground (most normal people can reach within 7 cm of the floor) or the level that the person can reach (eg, mid-tibia). The overall flexion is due to a combination of thoracic, lumbar and hip movements and does not distinguish between them. Lateral flexion: Ask the patient to slide their hands down the side of each leg in turn and record the point reached, either in centimeters from the floor or the position that the fingers reach on the legs. The contributions of the thoracic and lumbar spine are usually equal.

3 Rotation: The patient should be seated and asked to twist or standing with you stabilizing hips by placing the on iliac crest. Hip Check the hip joints for range of movement and for pain or limitation. Hip problems may present with predominantly back and buttock pain as well as pain in the groin. A loss of range on internal rotation of the hip is often the earliest sign of hip disease. Osteoarthritis of the hip may be clinically confused with low back pain, particularly a prolapsed intervertebral disc. Sacroiliac Joint: With the patient lying prone, elicit sacroiliac joint tenderness by applying firm pressure with one hand over the sacrum and the upper natal cleft. Then flex the hip and knee and then adduct the hip. Pain may indicate sacroiliac joint involvement, such as in ankylosing spondylitis or Reiter's syndrome. Provide Feedback Strength Hip flexion (L1) Hip adduction (L2) Knee extension (L3) Ankle dorsiflexion (L4) Great-toe dorsiflexion (L5) Ankle eversion (S1) MUSCLE STRENGTH MYOTOMES L1,L2, L3: hip flexion and internal rotation. L2, L3: hip adduction L4, L5: hip extension and external rotation. L4,L5: hip abduction L3, L4: knee extension. L5, S1: knee flexion. L4, L5: ankle dorsiflexion. S1, S2: ankle plantar flexion.

4 L4: ankle inversion. L5: Great toe extension L5, S1: ankle eversion. S1: walking on toes Dermatomes: L2: upper thigh. L3: knee. L4: medial aspect of the leg. L5: lateral aspect of the leg, medial side of the dorsum of the foot. S1: lateral aspect of the foot, the heel and most of the sole. S2: posterior aspect of the thigh. S3-S5: concentric rings around the anus, the outermost of which is S3. Neurovascular Patellar reflex (L4) Achilles reflex (S1-2) DTR 0 No evidence of contraction 1+ Decreased, but still present (hypo-reflexic) 2+ Normal 3+ Super-normal (hyper-reflexic) 4+ Clonus: Repetitive shortening of the muscle after a single stimulation Saddle Anesthesia Medial ankle (L4) Dorsum foot (L5) Lateral foot/sole (S1) SPECIFIC TEST Straight leg raising: Ask the patient to lie down on their back. Have the patient completely relax the affected leg. Cup the heel of their foot and gently raise the leg.

5 Passively flex the thigh with extended leg while the patient is supine. (Raise leg)dorsiflexion of the foot helps to elicit pain. Stop when the patient complains of back or leg pain (hamstring tightness is not relevant). The test is negative if there is no pain. Paraesthesiae or pain in root distribution is very significant, indicating nerve root irritation.suspected prolapsed intervertebral disc. If there is nerve root irritation, the patient will experience their typical pain when the leg is elevated between 30 and 60 degrees. This is referred to at the "straight leg raise test" and is sensitive for identifying root pathology (i.e. if it does not reproduce pain, root irritation unlikely). Sensitive (75-90%), but not specific. Therefore, negative test helps rule out nerve root irritation as cause of pain. d. If the straight leg test is positive, repeat the same test on the opposite leg. This is called the crossed straight leg raised test and is 85-95% specific for root irritation, but not sensitive. Therefore, positive test makes root irritation the likely etiology of the symptoms. Trendelenburg test: The patient is asked to stand in the neutral position, then lift one foot off the ground, while examiner s hands rest on the iliac crest. In a negative test (right), the hip elevates towards the weight-bearing side. In a positive test (left), the hip drops on affected side, suggesting gluteus medius pathology due to gluteus medius weakness which is innervated by L5 Slump test: The examiner passively dorsiflexes the patient s foot while keeping the neck in flexion. Pain and/or discomfort in the low back or leg suggests neural tension. Bowstring test: Once the level of pain has been reached, flex the knee slightly and apply firm pressure with the thumb in the popliteal fossa over the stretched tibial nerve. Radiating pain and paraesthesiae suggest nerve root irritation. Lasegue's sign: With the patient supine and hip flexed, dorsiflexion of the ankle causes pain or muscle spasm in the posterior thigh if there is lumbar root or sciatic nerve irritation.

6 Femoral stretch test: With the patient prone and the anterior thigh fixed to the couch, flex each knee in turn. This causes pain in the appropriate distributions by stretching the femoral nerve roots in L2-L4. The pain produced is normally aggravated by extension of the hip. The test is positive if pain is felt in the anterior compartment of the thigh. Neurological involvement Test the patellar (L3, L4) and Achilles (L5, S1) reflexes. Root pressure from a disc may affect myotomes and dermatomes in a selective fashion; record any muscle wasting (compare girths of calf and thigh muscles): Performing the test with the patient's arms folded across their chest gives a more accurate assessment. Schober's test: When the spine flexes, the distance between each pair of vertebral spines increases. Schober's test can be used to provide a quantitative evaluation of flexion of the lumbar spine. A tape with a 15 cm mark is placed vertically in the midline upwards from the level of the dimples at the level of the posterior superior iliac spines). Mark the skin at 0 and at 15 cm and then ask the patient to flex as far forward as they can. Record where the 15 cm mark on the skin strikes the tape. The increased distance along the tape is due only to flexion of the lumbar spine and is normally about 6-7 cm (less than 5 cm should be considered as abnormal). Flexion in the thoracic spine may be measured with the upper point 30 cm from the previous zero mark. Thoracic flexion is normally only about 3 cm. Extension: Ask the patient to arch their back; pain and restricted extension are particularly common in a prolapsed intervertebral disc and spondylolysis. Maximum range is thoracic 25 and lumbar 35. There are a variety of ominous processes that cause low back pain, particularly in older patients (> 50). These problems carry significant morbidity and mortality and mandate a focused and rapid evaluation (including lab and imaging studies) different from what is required for the relatively benign processes described above. Careful history taking and examination can help distinguish these problems. Historical keys include: Pain that doesn't get better when lying down/resting.

7 Pain associated by systemic symptoms of inflammation (e.g. fever, chills), in particular in those at risk for systemic infection that could seed the spinal area (e.g. IV drug users, patients with bacteremia). Known history of cancer, in particular malignancies that metastasize to bone (e.g. prostate, breast, lung). Trauma, particularly if of substantial force. Osteoporosis Which increases risk of compression fracture ( vertebrae collapsing under the weight they must bear). More common in women > men as people age. In particular, weakness in legs suggesting motor dysfunction. Also, bowel or bladder incontinence, implying diffuse sacral root dysfunction. Note: it can sometimes be difficult to distinguish true weakness from motor limitation caused by pain. Pain referred to the back from other areas of the body (e.g. intra-abdominal or retroperitoneal processes). Could include: Pyelonephritis, leaking/rupturing abdominal aortic aneurysm, posterior duodenal ulcer, pancreatitis, etc. Non-specific musculoskeletal pain: This is the most common cause of back pain. Patients present with lumbar area pain that does not radiate, is worse with activity, and improves with rest. There may or may not be a clear history of antecedent over use or increased activity. The pain is presumably caused by irritation of the paraspinal muscles, ligaments or vertebral body articulations. However, a precise etiology is difficulty to identify. Radicular Symptoms: Often referred to as "sciatica," this is a pain syndrome caused by irritation of one of the nerve roots as it exits the spinal column. The root can become inflamed as a result of: 1. a compromised neuroforamina (e.g. bony osteophyte that limits size of the opening) 2. or a herniated disc (the fibrosis tears, allowing the propulsus to squeeze out and push on the adjacent root). 3. Sometimes, it's not precisely clear what has lead to the irritation. In any case, patient's report a burning/electric shock type pain that starts in the low back, traveling down the buttocks and along the back of the leg, radiating below the knee. The most commonly affected nerve roots are L5 and S1.

8 Spinal Stenosis: Pain starts in lower back and radiates down buttocks BILATERALLY, continuing along the back side of BOTH legs. Symptoms are usually worse with walking and improve when the pt. bends forward. Like leaning on grocery cart. This is caused by spinal stenosis, a narrowing of the central canal that holds the spinal cord. The limited amount of space put pressure on the nerve roots when the pt. walks, causing the symptoms ( referred to as neurogenic claudication ). Spinal stenosis can be congenital or develop over years as a result of DJD of the spine. As opposed to true claudication ( pain in calves/ lower legs due to arterial insufficiency), pain resolves quickly when person stops walking and assumes upright position. Also, peripheral pulses are nl. Mixed symptoms: In some patients, more then one process may co-exist, causing elements of more then one symptom syndrome to co-exist. Epidemiology I95% involve L4/5 or L5/S1 levels L5/S1 most common level peak incidence is 4th and 5th decades only ~5% become symptomatic 3:1 male:female ratio Imaging Radiographs may show loss of lordosis (spasm) loss of disc height lumbar spondylosis (degenerative changes) MRI without gadolinium modality of choice for diagnosis of lumbar and cervical disc herniations highly sensitive and specific helpful for preoperative planning useful to differentiate from synovial facet cysts however high rate of abnormal findings on MRI in normal people

9 Indications for obtaining an MRI pain lasting > one month and not responding to nonoperative management or red flags are present infection (IV drug user, h/o of fever and chills) tumor (h/o or cancer) trauma (h/o car accident or fall) cauda equina syndrome (bowel/bladder changes) MRI with gadolinium useful for revision surgery allows to distinguish between post-surgical fibrosus (enhances with gadolinium) vs. recurrent herniated disc (does not enhance with gadolinium) Pathoanatomy recurrent torsional strain leads to tears of outer annulus which leads to herniation of nucleus pulposis Prognosis 90% of patients will have improvement of symptoms within 3 months with nonoperative care. size of herniation decreases over time (reabsorbed) Location Classification central prolapse often associated with back pain only may present with cauda equina syndrome which is a surgical emergency posterolateral (paracentral) most common (90-95%) PLL is weakest here affects the traversing/descending/lower nerve root at L4/5 affects L5 nerve root foraminal (far lateral, extraforaminal) post less common (5-10%) affects exiting/upper nerve root at L4/5 affects L4 nerve root

10 Anatomic classification protrusion eccentric bulging with an intact annulus extrusion disc material herniates through annulus but remains continuous with disc space sequestered fragment (free) disc material herniates through annulus and is no longer continuous with disc space Treatment Plans Nonoperative rest and physical therapy, and antiinflammatory medications indications first line of treatment for most patients with disc herniation 90% improve without surgery technique bedrest followed by progressive activity as tolerated medications NSAIDS muscle relaxants (more effective than placebo but have side effects) oral steroid taper physical therapy extension exercises extremely beneficial traction chiropractic manipulation selective nerve root corticosteroid injections indications Second line of treatment if therapy and medications fail technique epidural selective nerve block outcomes leads to long lasting improvement in ~ 50% (compared to ~90% with surgery) results best in patients with extruded discs as opposed to contained discs Operative laminotomy and discectomy (microdiscectomy) post indications persistent disabling pain lasting more than 6 weeks that have failed nonoperative options (and epidural injections)

11 progressive and significant weakness cauda equina syndrome technique can be done with small incision or through "tube" access Outcomes outcomes with surgery compared to nonoperative improvement in pain and function greater with surgery positive predictors for good outcome with surgery leg pain is chief complaint positive straight leg raise weakness that correlates with nerve root impingement seen on MRI married status negative predictors for good outcome with surgery worker's compensation WC patients have less relief from symptoms and less improvement in quality of life with surgical treatment Complications of Surgery Dural tear (1%) if have tear at time of surgery then perform water-tight repair Recurrent HNP can treat nonoperatively initially outcomes for revision discectomy have been shown to be as good as for primary discectomy Discitis (1%) Vascular catastrophe caused by breaking through anterior annulus and injuring vena cava/aorta

12 Original Author: Dr Colin Tidy Current Version: Dr Laurence Knott Peer Reviewer: Dr John Cox Document ID: 1095 (v23) Last Checked: 21/08/2014 Next Review: 20/08/2019 Web Site Design by Jan Thompson, Program Representative, UCSD School of Medicine. Content and Photographs by Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, California Send Comments to: Charlie Goldberg, M.D. Orthobullets web site

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