At the risk of repetition of the points made in the discussion of neck and thoracic pain, don’t start your interview until you have a list of diagnostic possibilities in mind (Table 3-1 and Figures 3-1 and 3-2). Another excellent mnemonic to help you with this is VINDICATE:

V—Vascular (aortic aneurysm)

I—Inflammation (epidural abscess, osteomyelitis, sacroiliitis, rheumatoid spondylosis, herpes zoster, prostatitis, PID, etc.)

N—Neoplasm (primary or metastatic tumors of the spine, ovarian tumors, endometriosis)

D—Degenerative (lumbar spondylosis, herniated disc, osteoporosis)

I—Intoxication (radiculoneuropathies)

C—Congenital disorders (spondylolisthesis, scoliosis, spina bifida, ochronosis, etc.)

A—Autoimmune disorders (rheumatoid spondylitis)

T—Traumatic disorders (fracture, herniated disc, sprains, etc.)

E—Endocrine disorders (diabetic radiculoneuropathy, osteoporosis)

Onset: An acute onset suggests an infectious process such as epidural abscess, osteomyelitis, prostatitis and PID, or trauma (fracture, herniated disc, sprain), while a gradual onset of chronic low back pain suggests a primary or metastatic neoplasm or degenerative process (lumbar spondylosis, osteoporosis, etc.). If the pain began after an accident, you need the details.

Radiation of the Pain: Radiation of the pain to the buttocks or extremities would suggest a space-occupying lesion such as herniated disc, epidural abscess, or neoplasm.

Aggravation Relief or Precipitation of the Pain: Aggravation of the pain on flexion might suggest a herniated disc, while aggravation on extension would suggest a facet syndrome from spondylosis (osteoarthritis). If the pain persists while lying down, you must consider a neoplasm. Precipitation of the pain in the hips or extremities on walking a certain

distance suggests neurogenic or vascular claudication. Aggravation of the pain on coughing, sneezing, or straining during a bowel movement would suggest a herniated disc or other space-occupying lesion.

Associated Symptoms: Fever or chills suggest an infectious process such as an epidural abscess, osteomyelitis, prostatitis, or PID. Painful intercourse or irregular menses suggests PID or endometriosis as well as other pelvic pathology. Weakness, paresthesias of the extremities, or gait disturbances point to a radiculopathy. When these symptoms are combined with difficulty voiding or loss of bladder control, one must consider a cauda equina syndrome.

Review of Systems: A careful review of systems is helpful but can be simplified by asking the following questions:

1. Is there pain anywhere else?

2. Is there bleeding from any body orifice?

3. Is there a discharge from any body orifice?

4. Is there a lump or bump anywhere?

5. Is there dysfunction of any organ system? (Difficulty swallowing, breathing, having an erection, indigestion, hearing, seeing, moving your bowels, voiding, walking, etc.).

Past History: Ask about recent or past injuries or accidents, surgeries or hospitalizations. Is there a history of heart disease, lung disease, liver disease, kidney disease, intestinal disease, neurologic disease, or skin, bone, or joint disease? Don’t forget psychiatric disease, drug or alcohol addiction, and pending litigation.

Family History: A family history of diabetes, scoliosis, or neuromuscular disorder is important.

Summary: Again it is important to emphasize that just like with neck and thoracic pain the object of the history is to determine if you, the primary
care provider, can treat the patient with low back pain conservatively or need to make a referral for more aggressive action.

The examination of the patient with back pain need not take a lot of time. With a little practice, it can be accomplished in 10 to 15 minutes.

Begin the exam by having the patient walk normally back and forth in the exam room. Look for a steppage gait or footdrop or a limp. Have the patient walk on his/her heels (Figure 3-3), which may demonstrate weakness of dorsiflexion of the foot and toes indicating an L5 radiculopathy or peroneal neuropathy. Next, have the patient walk on his/her toes (Figure 3-4). This may indicate an S1 radiculopathy. Then have the patient
stand at ease with the legs 12 inches apart and palpate the erector spinae muscles for muscle spasm (Figure 3-5). Normally the muscles will be soft and doughty, but in lumbosacral spine pathology, they can be mildly tight or stiff as a board unilaterally or bilaterally.

Test the range of motion of the lumbar spine by having the patient bend over as far as he or she can before experiencing pain (Figure 3-6) and then extending to the point of pain (Figure 3-7). Normally, patients can extend 25 degrees and bend 75 to 90 degrees. Lateral bending should also be tested (Figure 3-8). This is normally 25 to 30 degrees.

Now, have the patient sit on the end of the exam table and perform straight leg raising (Figure 3-9). Normally there should be no leg pain or restriction to 80 to 90 degrees unless there are short hamstrings. If the patient experiences only an increase in low back pain, the test is negative. Next, have the patient lie down and perform the same maneuver (Figure 3-10).

If he/she is malingering, leg pain may only be experienced in the recumbent position. This is a good place to check for a short leg by simply having the patient stretch the legs out together and observing whether the heels appear at equal length or medial malleoli touch. If there is any doubt, measure the distance between the anterior superior iliac spine and the medial malleolus on each leg (Figure 3-11).

Confirm your findings on the SLR by performing a Lasègue sign (Figure 3-12). Next, perform the femoral stretch on each leg (Figure 3-13) Anterior-thigh pain or resistance anywhere before 80 to 90 degrees may indicate an L3 or L4 radiculopathy.

Test sensation to touch and pain on the big and little toes on each foot and compare the results by testing back and forth (Figure 3-14). The lateral and medial surfaces of the feet may be substituted if there are calluses. Loss of sensation to touch and or pain on the big toe may indicate an L5 radiculopathy, while loss on the little toe may indicate an S1 radiculopathy.

In like manner, test the sensation to touch and pain on the medial and lateral surfaces of the anterior thigh (Figure 3-15). Loss of sensation over the anterolateral thigh suggests an L4 radiculopathy, while loss of




sensation over the anteromedial surface may indicate an L3 radiculopathy. If a cauda equina lesion is suspected, test the sensation over the sacrum (Figure 3-16).

Next, we need to assess muscle power. Check the power of dorsiflexion of the toes and feet (Figure 3-17) on each extremity and note any difference. Weakness of dorsiflexion of the big toe is almost always due to an L5 radiculopathy or peroneal neuropathy. In like manner, check the power of extension (or plantar flexion) of the foot and toes (Figure 3-18).

Move on to testing the power of knee flexion (Figure 3-19) and extension (Figure 3-20). Note any difference. Weakness on extension is often an indication of L4 radiculopathy.

The deep tendon reflexes are next tested at the knee and ankle and checked for comparison (Figure 3-21). An absent ankle jerk on one extremity is strong evidence of an S1 radiculopathy, while a diminished ankle jerk may indicate an L5 or S1 radiculopathy. A diminished knee jerk on one lower extremity suggests an L4 radiculopathy.

Look for atrophy (usually a clear indication for surgery) at the calf and thigh by measuring the circumference of the calf at the bulkiest point on each leg and the circumference of the thigh at just above the knee (Figure 3-22). Compare the results on one leg with the other.

Look for fasciculations of the muscles of the thigh and calf if you have not already observed for them before (Figure 3-23). The possibility that the back and/or hip pain are due to hip pathology always exists, so perform a Patrick test (Figure 3-24) by crossing each lower leg over the opposite thigh and pressing the knee of the crossed leg to see if pain can be elicited. If pain is elicited, check further for hip pathology. Finally, palpate the back for trigger points and sacroiliac tenderness (Figure 3-25). Check for malingering or hysteria by doing an axial rotation test (Figure 3-26). With the patient standing and one hand on the shoulder and the other on the opposite hip, rotate the patient’s body to the right and left. If back pain is elicited, the patient is likely malingering. Be sure to check the arterial pulses (Figure 3-27) to be sure the leg pain is not vascular in origin. Table 3-2 summarizes the neurologic findings in the most common forms of lumbar radiculopathy.