REIDER PART 286

346 Chapter 9 Lumbar Spine

9-3 • When the Patient Complains of Low-Back Pain without Preceding Trauma

Major Diagnostic Possibilities Include:

Low-back strain Degenerative disc disease Lumbar arthritis Herniated disk

Spondylolysis/spondylolisthesis Spinał deformity Compression fracture Infection Tumor

Nonorganic low-back pain Patient Age:

In patients less than 20 years old:

• Spondylolysis; isthmic spondylolisthesis

• Tumor

In patients 20 to 50 years:

• Low-back strain

• Degenerative disk disease

• Herniated disk

• Spondylolisthesis

• Nonorganic low-back pain

In patients older than 50 years:

• Low-back strain

• Lumbar arthritis

• Compression fracture

• Infection

• Tumor

• Nonorganic low-back pain General Medical History:

• If the patient is immunocompromised or has a history of intravenous drug abuse

- Infection is a strong possibility

• If the patient has a history of cancer

- Metastatic spread to the lumbar spine must be suspected

• If the patient has a history of osteoporosis

-Compression fracture should be considered

Ask the Patient to Describe Associated Symptoms:

• Constitutional symptoms such as weight loss, fever, or night sweats

-Suggestive of tumor or infection

• Unilateral leg paresthesias, weakness and pain

-Typical of herniated disk

- May be suggestive of lumbar arthritis with spinał stenosis

• Bilateral buttock/leg pain and cramping with ambulation

-Suggestive of lumbar arthritis with spinał stenosis

- Other possibilities include tumor or trauma resulting in neural compression

• Bowel or bladder symptoms

- May be the result of neural compression caused by a larger disc herniation, tumor or fracture

Relevant Physical Examination:

General:

Inspection Palpation

Examination of gait Rangę of motion Neurologie testing

Compression fracture:

Palpation for tenderness at the leve! of injury Inspection for swelling and ecchymosis at the level of injury

Palpation for step-off Pain with rangę of motion

Spondylolysis/Spondylousthesis:

Inspection for decreased lumbar lordosis Hyperextension of lumbar spine to determine if pain reproduced Palpation for step-off

Straight-leg raising test to elicit hamstring tightness Neurologie testing

Lumbar spondylosis:

Decreased lumbar rangę of motion Pain with lumbar rangę of motion

nfection/Tumor:

Palpation for point tenderness at involved level Palpation for associated muscle spasm Neurologie testing

Spinał stenosis:

Inspection for loss of lumbar lordosis Sciatic notch tenderness Passive spine extension reproduces neurogenic claudication

Vascular examination to exclude vascular claudication Herniated disk:

Nerve root tension tests (straight-leg raising, Lasegue's test, contralateral straight-leg raising, slump test, bowstring sign)

Flexion of lumbar spine to reproduce leg symptoms Palpation of sciatic notch for tenderness Neurologie testing for deficit in the distribution of the involved root Low-back strain:

Palpation for paraspinal muscle tenderness or spasm

Inspection of gait for list (variable)

Neurologie examination should be normal Nonorganic low-back pain

• WaddelTs signs