CAUSES
β’ Aging
β’ Trauma, major or minor
β’ Frequent lifting of objects weighing 25 pounds (11.3 kg) or more, especially if lifted with arms extended and knees straight, and body twisted
β’ Vibration; e.g., driving motor vehicles
β’ Workerβs disability is linked to physical and social aspects of job
--------------------------------------------------------------------------
DIFFERENTIAL DIAGNOSIS
β’ Acute or chronic lumbosacral strain
β’ Spondylolysis
β’ Spondylolisthesis
β’ Spinal arthritis
β’ Fibrositis
β’ Cauda equina syndrome
β’ Compression fracture
β’ Poor posture
β’ Bursitis
β’ Metastatic and primary tumors
β’ Vertebral infection
β’ Pain referred from hip, retroperitoneum, aneurysms, or pelvis (geriatrics), neurogenic claudication
β’ Signs and symptoms that suggest a more serious etiology include: age > 50, constitutional symptoms, night pain, recent infection, history of cancer, immunosuppression ,IV drug use. Signs of cauda equina syndrome
are peroneal anesthesia, bowel or bladder dysfunction, and severe lower extremity neurological losses
LABORATORY ESR or C-reactive protein - usually normal
SPECIAL TESTS
. Electromyography - useful to exclude peripheral neuritis
IMAGING
There are few critical evaluations of imaging techniques of diagnostic and therapeutic impact.
. Lumbosacral plain films: rarely indicated just to initiate a conservative management program - primary screening method to rule out tumor or structural abnormality although presence of latter may not confirm source of pain. Schmorl nodes are common and associated with moderate degenerative changes of the spine.
. Lumbosacral oblique views: may be helpful
. MRI now preferred over CT scan and myelogram (for surgical candidate evaluation). Notes: disk herniation found in 20-35% and disk bulging in 56% of asymptomatic adults < 60 years.
DIAGNOSTIC PROCEDURES
. Examine gait, posture, motion and inconsistent pain responses
. Neurologic defects of lower extremities and perineum will usually locate level of lesion. Test above plus reflexes, motor strength, muscle atrophy; pulses and
abdominal bruits; rectal sphincter.
. Other physical exam tests
. Straight leg raise (SLR): (sitting or supine) elevation of affected leg < 70 DEGREEelicits pain in leg. Pain in back, hip, butt is negative.
. Contralateral SLR: (sitting or supine) elevating normal leg produces sciatica down other leg
. Sciatic stretch: (supine) elevation of affected leg (to 15-30 DEGREE for severe, 30-60 DEGREE, milder) elicits pain indicating L2-3 source. Tip: compare to sitting position looking for learned behavior.
. Lasegues sign: (supine) hip flexed, dorsiflexion of ankle accentuates sciatic pain or muscle spasm in posterior thigh
. Hoovers: (supine) tests active effort for SLR; put hand under contralateral heel to reveal downward force
. Femoral stretch: (prone) affected leg is extended from knee reproducing pain along femoral nerve (L2-3)
. Fabers: (supine) flexion, abduction and external rotation of hip produces pain indicating hip or sacroiliac source of pain