pain in the lower back and limbs

8/13/2019 Pain in the Lower Back and Limbs

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PAIN IN THE LOWER BACK AND LIMBS

The lower parts of the spine an pel!is" with their #assi!e #$s%$lar atta%h#ents"

are relati!el& ina%%essi'le to palpation an inspe%tion( Altho$)h so#e ph&si%al si)ns

an raio)raphs are helpf$l" ia)nosis often epens on the patient*s es%ription of

the pain an his or her 'eha!ior $rin) the e+e%$tion of %ertain #ane$!ers(Seasone %lini%ians" for these reasons" ha!e %o#e to appre%iate the nee for a

s&ste#ati% in,$ir& an #etho of e+a#ination" the es%riptions of whi%h are

pre%ee here '& a 'rief %onsieration of the anato#& an ph&siolo)& of the spine(

Anato#& an Ph&siolo)& of the Lower Part of the Ba%-

The 'on& spine is a %o#ple+ str$%t$re" ro$)hl& i!isi'le into an anterior an a

posterior part( The for#er %onsists of a series of %&linri% !erte'ral 'oies"

arti%$late '& the inter!erte'ral is%s an hel to)ether '& the anterior an

posterior lon)it$inal li)a#ents( The posterior ele#ents are #ore eli%ate an

e+ten fro# the 'oies as pei%les an la#inae that for#" with the posterioraspe%ts of the 'oies an li)a#ents" the !erte'ral %anal( Sto$t trans!erse an

spino$s pro%esses pro.e%t laterall& an posteriorl&" respe%ti!el&" an ser!e as the

ori)ins an insertions of the #$s%les that s$pport an prote%t the spinal %ol$#n(

The 'on& pro%esses are also hel to)ether '& st$r& li)a#ents" the #ost i#portant

'ein) the li)a#ent$# fla!$#( The posterior parts of the !erte'rae arti%$late with

one another at the iarthroal apoph&seal /fa%et0 .oints" ea%h of whi%h is %o#pose

of the inferior fa%et of the !erte'ra a'o!e an the s$perior fa%et of the one 'elow(

These anato#i% feat$res are ill$strate in 1i)( 2232 an 1i)( 2234( The fa%et an

sa%roilia% .oints" %o!ere '& s&no!ia" the %o#pressi'le inter!erte'ral is%s" an the

%olla)eno$s an elasti% li)a#ents per#it a li#ite e)ree of fle+ion" e+tension"

rotation" an lateral #otion of the spine(

1i)$re 2232 The fifth l$#'ar !erte'ra !iewe fro# a'o!e /A0 an fro# the sie /B0


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1i)$re 2234 The #ain li)a#ento$s str$%t$res of the spine( A( B$%-lin) of the &ellow

li)a#ent /li)a#ent$# fla!$#0 #a& %o#press the ner!e root or the spinal ner!e at

its ori)in in the inter!erte'ral fora#en" parti%$larl& if the fora#en is narrowe '&

osteoph&ti% o!er)rowth( B( Posterior aspe%t of the !erte'ral 'oies( 1i'ers of theposterior lon)it$inal li)a#ent #er)e with the postero#eial portion of the ann$l$s

fi'ros$s" lea!in) the posterolateral portion of the ann$l$s relati!el& $ns$pporte(

/Reprinte '& per#ission fro# 1inneson(0

The sta'ilit& of the spine epens on the inte)rit& of the !erte'ral 'oies an

inter!erte'ral is%s an on two t&pes of s$pportin) str$%t$res" li)a#ento$s

/passi!e0 an #$s%$lar /a%ti!e0( Altho$)h the li)a#ento$s str$%t$res are ,$ite

stron)" neither the& nor the !erte'ral 'o&5is% %o#ple+es ha!e s$ffi%ient inte)ralstren)th to resist the enor#o$s for%es that #a& a%t on the spinal %ol$#n6 the

sta'ilit& of the lower 'a%- is therefore lar)el& epenent on the !ol$ntar& an refle+

a%ti!it& of the sa%rospinalis" a'o#inal" )l$te$s #a+i#$s" an ha#strin) #$s%les(

The !erte'ral an para!erte'ral str$%t$res eri!e their inner!ation fro# the

#enin)eal 'ran%hes of the spinal ner!es /also -nown as re%$rrent #enin)eal or

sin$!erte'ral ner!es0( These #enin)eal 'ran%hes sprin) fro# the posterior i!isions

of the spinal ner!es .$st istal to the orsal root )an)lia" re3enter the spinal %anal

thro$)h the inter!erte'ral fora#ina" an s$ppl& pain fi'ers to the intraspinal

li)a#ents" perioste$# of 'one" o$ter la&ers of the ann$l$s fi'ros$s /that en%lose

the is%0" an %aps$le of the arti%$lar fa%ets( Coppes an asso%iates ha!e fo$n A3

an C pain fi'ers e+tenin) into the inner la&ers of the ann$l$s an e!en the

n$%le$s p$lpos$s( Altho$)h the spinal %or itself is insensiti!e" #an& of the

%onitions that affe%t it pro$%e pain '& in!ol!in) these a.a%ent str$%t$res( The

sensor& fi'ers fro# these str$%t$res an the l$#'osa%ral an sa%roilia% .oints enter

the spinal %or !ia the fifth l$#'ar an first sa%ral roots( Motor fi'ers e+it thro$)h

the %orresponin) anterior roots an for# the efferent li#' of se)#ental refle+es(

The spatheti% ner!es %ontri'$te onl& to the inner!ation of 'loo !essels( The

spinal roots in the l$#'ar re)ion" after e+itin) fro# the spinal %or" %o$rse

ownwar in the spinal %anal an are )ra$all& ispla%e laterall& $ntil the&

an)$late an e+it at the inter!erte'ral fora#ina( Prior to enterin) the shortfora#inal %anal" the spinal root lies in a shallow f$rrow alon) the inner s$rfa%e of

the pei%le ter#e the lateral re%ess( This is a %o##on site of root entrap#ent '&

is% fra)#ents an 'on& o!er)rowth(

The parts of the 'a%- that possess the )reatest freeo# of #o!e#ent an hen%e

are #ost fre,$entl& s$'.e%t to in.$r& are the l$#'ar" l$#'osa%ral" an %er!i%al( In


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aition to 'enin)" twistin)" an other !ol$ntar& #o!e#ents" #an& a%tions of the

spine are refle+i!e in nat$re an are the 'asis of post$re(

A)in) Chan)es in Spinal Str$%t$res Chan)es in the inter!erte'ral is%s an

li)a#ents as a %onse,$en%e of a)in) an perhaps a s$%%ession of #inor tra$#as

'e)in to o%%$r as earl& as the first part of the thir e%ae( Deposition of %olla)enan elastin an alterations of )l&%osa#ino)l&%ans %o#'ine to e%rease the water

%ontent of the n$%le$s p$lpos$s6 %on%o#itantl&" the %artila)eno$s en plate

'e%o#es less !as%$lar /Hassler0( The eh&rate is% thins o$t an 'e%o#es #ore

fra)ile( Si#ilar %han)es o%%$r in the ann$l$s of the is%" whi%h fra&s to an

in%reasin) e)ree with the passa)e of ti#e" per#ittin) the n$%le$s p$lpos$s to

'$l)e an" so#eti#es with in.$r&" to e+tr$e( This pro%ess %an 'e o'ser!e '&

#a)neti% resonan%e i#a)in) /MRI0" whi%h shows a )ra$al re$%tion in the hi)h

si)nal of the n$%le$s p$lpos$s with the passa)e of ti#e( In wo#en who ha MRI for

)&ne%olo)i% reasons" Powell an %owor-ers fo$n an in%reasin) fre,$en%& of l$#'ar

is% e)eneration an '$l)in)" approa%hin) 78 per%ent '& the fiftieth &ear of life(

Si#ilar a'nor#alities in aspto#ati% #en an wo#en ha!e 'een re%ore '&9ensen an %ollea)$es( The shrin-a)e of the is% alters the ali)n#ent of the

arti%$lar fa%ets an !erte'ral 'oies" leain) so#eti#es to fa%et arthropath& an

sp$r for#ation( The latter %han)es #a& %ontri'$te to stenosis of the spinal %anal

an %o#pro#ise the lateral re%esses of the %anal an the inter!erte'ral fora#ina"

where the& #a& i#pin)e on ner!e roots( Osteoporosis" espe%iall& in oler wo#en" is

an i#portant %a$se of !erte'ral flattenin) or %ollapse" aitionall& narrowin) the

spinal %anal(

:eneral Clini%al 1eat$res of Low3Ba%- Pain

T&pes of Low3Ba%- Pain Of the se!eral spto#s of spinal isease /pain" stiffness"li#itation of #o!e#ent" an efor#it&0" pain is of fore#ost i#portan%e( 1o$r t&pes

of pain #a& 'e istin)$ishe; lo%al" referre" rai%$lar" an that arisin) fro#

se%onar& /prote%ti!e0 #$s%$lar spas#( These se!eral t&pes of pain %an often 'e

is%erne fro# the patient*s es%ription6 relian%e is pla%e #ainl& on the %hara%ter

of the pain" its lo%ation" an %onitions that #oif& it(

Lo%al pain is %a$se '& an& patholo)i% pro%ess that i#pin)es $pon str$%t$res

%ontainin) sensor& enin)s( In!ol!e#ent of the perioste$#" %aps$le of apoph&seal

.oints" #$s%les" ann$l$s fi'ros$s" an li)a#ents is often e+,$isitel& painf$l" whereas

estr$%tion of the !erte'ral 'o& or n$%le$s p$lpos$s alone pro$%es little or no

pain( Lo%al pain is #ost often es%ri'e as stea& an a%hin)" '$t it #a& 'e

inter#ittent an sharp an" tho$)h not well %ir%$#s%ri'e" is alwa&s felt in or near

the affe%te part of the spine(


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are %ontin$all& in refle+ spas# #a& also 'e%o#e tener an sensiti!e to eep

press$re(

Referre pain is of two t&pes" one that is pro.e%te fro# the spine to !is%era an

other str$%t$res l&in) within the territor& of the l$#'ar an $pper sa%ral

er#ato#es an another that is pro.e%te fro# pel!i% an a'o#inal !is%era to thespine( Pain $e to isease of the $pper part of the l$#'ar spine is often referre to

the flan-" lateral hip" )roin" an anterior thi)h( This has 'een attri'$te to irritation

of the s$perior %l$neal ner!es" whi%h are eri!e fro# the posterior i!isions of the

first three l$#'ar spinal ner!es an inner!ate the s$perior portions of the '$tto%-s(

Pain fro# the lower part of the l$#'ar spine is $s$all& referre to the lower

'$tto%-s an posterior thi)hs an is $e to irritation of lower spinal ner!es" whi%h

a%ti!ate the sa#e pool of intraspinal ne$rons as the ner!es that inner!ate the

posterior thi)hs( Pain of this t&pe is $s$all& rather iff$se an has a eep" a%hin)

,$alit&" '$t it tens at ti#es to 'e #ore s$perfi%iall& pro.e%te( M%Call an

%ollea)$es an Kell)ren ha!e !erifie these areas of referen%e '& the in.e%tion of

h&pertoni% saline into the apoph&seal .oints( B$t" as Sin%lair an %owor-ers ha!epointe o$t" the sites of referen%e are ine+a%t an %annot 'e relie $pon for the

pre%ise anato#i% lo%ali=ation of lesions( In )eneral" the intensit& of the referre pain

parallels that of the lo%al pain( In other wors" #ane$!ers that alter lo%al pain ha!e

a si#ilar effe%t on referre pain" tho$)h la%-in) the pre%ision an i##eia%& of so3

%alle root pain(

Pain fro# !is%eral iseases is $s$all& felt within the a'o#en" flan-s" or l$#'ar

re)ion an #a& 'e #oifie '& the state of a%ti!it& of the !is%era an so#eti#es '&

ass$#in) an $pri)ht or s$pine post$re( Its %hara%ter an te#poral relationships

ha!e little relationship to #o!e#ent of the 'a%-(

Rai%$lar" or >root"? pain has so#e of the %hara%teristi%s of referre pain '$t iffers

in its )reater intensit&" istal raiation" %ir%$#s%ription to the territor& of a root" an

fa%tors that e+%ite it( The #e%hanis# is stret%hin)" irritation" or %o#pression of a

spinal root" within or %entral to the inter!erte'ral fora#en( The pain is sharp" often

intense" an $s$all& s$peri#pose on the $ll a%he of referre pain6 it nearl&

alwa&s raiates fro# a para%entral position near the spine to so#e part of the lower

li#'( Co$)hin)" snee=in)" an strainin) %hara%teristi%all& e!o-e this sharp raiatin)

pain" altho$)h ea%h of these a%tions #a& also .ar or #o!e the spine an enhan%e

lo%al pain6 .$)$lar !ein %o#pression" whi%h raises intraspinal press$re an #a&

%a$se a shift in position of the root" has a si#ilar effe%t( In fa%t" an& #ane$!er thatstret%hes the ner!e root@e()(" >strai)ht3le) raisin)? in %ases of s%iati%a@e!o-es

rai%$lar pain( The patterns of rai%$lar pain $e to in!ol!e#ent of parti%$lar roots

are es%ri'e in the se%tions on prolapse is%s /pa)es 42 an 445440( The

#ost %o##on pattern is s%iati%a" pain that ori)inates in the '$tto%- an is

pro.e%te alon) the posterior or posterolateral thi)h( It res$lts fro# irritation of the

L or S2 ner!e root( Paresthesias or s$perfi%ial sensor& loss" soreness of the s-in"

an tenerness in %ertain %ir%$#s%ri'e re)ions alon) the ner!e $s$all& a%%o#pan&


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rai%$lar pain( If the anterior roots are in!ol!e as well" there #a& 'e refle+ loss"

wea-ness" atroph&" an fas%i%$lar twit%hin)(

In patients with se!ere %ir%$#ferential %onstri%tion of the %a$a e,$ina $e to

spon&losis /l$#'ar stenosis0" sensori#otor i#pair#ent an so#eti#es referre

pain are eli%ite '& stanin) an wal-in)( The ne$rolo)i% spto#s in!ol!e the%al!es an the 'a%- of the thi)hs" si#$latin) the e+er%ise3in$%e spto#s $e to

!as%$lar ins$ffi%ien%&@hen%e the ter# spinal %la$i%ation /see pa)e 420(

Of i#portan%e is the o'ser!ation that referre pain fro# the lower 'a%- /so#eti#es

%alle pse$orai%$lar0 oes not" as a r$le" pro.e%t 'elow the -nees an is not

a%%o#panie '& ne$rolo)i% %han)es other than a !a)$e n$#'ness witho$t

e#onstra'le sensor& i#pair#ent( The s$'%$taneo$s tiss$es within the area of

referre pain #a& 'e tener( Of %o$rse" lo%al" referre" an rai%$lar pain #a&

o%%$r to)ether(

Pain res$ltin) fro# #$s%$lar spas# $s$all& o%%$rs in relation to lo%al pain( The

spas# #a& 'e tho$)ht of as a no%ifensi!e refle+ for the prote%tion of the isease

parts a)ainst in.$rio$s #otion( M$s%le spas# is asso%iate with #an& isorers of

the low 'a%- an %an istort nor#al post$re( Chroni% #$s%$lar %ontra%tion #a& )i!e

rise to a $ll" so#eti#es %ra#pin) a%he( One %an feel the ta$tness of the

sa%rospinalis an )l$teal #$s%les an e#onstrate '& palpation that the pain is

lo%ali=e to the#( Howe!er" e+%ept for the #ost se!ere e)rees of spas# in a%$te

in.$r& of the 'a%-" the %ontri'$tion of this %o#ponent to 'a%- pain is relati!el&

s#all(

Other pains" often of $neter#ine ori)in" are so#eti#es es%ri'e '& patients

with %hroni% isease of the lower part of the 'a%-; rawin) an p$llin) in the le)s"%ra#pin) sensation /witho$t in!ol$ntar& #$s%le spas#0" tearin)" thro''in)" or

.a''in) pains" an feelin)s of '$rnin) or %olness( These sensations" li-e

paresthesias an n$#'ness" sho$l alwa&s s$))est the possi'ilit& of ner!e or root

isease(

In aition to assessin) the %hara%ter an lo%ation of the pain" one sho$l

eter#ine the fa%tors that a))ra!ate an relie!e it" its %onstan%&" an its

relationship to a%ti!it& an rest" post$re" forwar 'enin)" an %o$)h" snee=e" an

strain( 1re,$entl& the #ost i#portant lea %o#es fro# -nowle)e of the #oe of

onset an the %ir%$#stan%es that initiate the pain( Inas#$%h as #an& painf$l

affe%tions of the 'a%- are the res$lt of in.$ries in%$rre $rin) wor- or in a$to#o'ilea%%ients" the possi'ilit& of e+a))eration or prolon)ation of pain for p$rposes of

%o#pensation #$st alwa&s 'e -ept in #in(

E+a#ination of the Lower Ba%-

So#e infor#ation #a& 'e )aine '& inspe%tion of the 'a%-" '$tto%-s" an lower

li#'s in !ario$s positions( The nor#al spine shows a thora%i% -&phosis an l$#'ar


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lorosis in the sa)ittal plane" whi%h in so#e ini!i$als #a& 'e e+a))erate

/swa&'a%-0( In the %oronal plane" the spine is nor#all& strai)ht or shows a sli)ht

%$r!at$re" parti%$larl& in wo#en( One sho$l o'ser!e the spine %losel& for

e+%essi!e %$r!at$re" a list" flattenin) of the nor#al l$#'ar lorosis" presen%e of a

)i''$s /a sharp" -&photi% an)$lation $s$all& ini%ati!e of a fra%t$re0" pel!i% tilt or

o'li,$it& /Trenelen'$r) si)n0" an as#etr& of the para!erte'ral or )l$teal#$s%$lat$re( A sa))in) )l$teal fol s$))ests in!ol!e#ent of the S2 root( In s%iati%a

one #a& o'ser!e a fle+e post$re of the affe%te le)" pres$#a'l& to re$%e tension

on the irritate ner!e( Patients in who# a free fra)#ent of l$#'ar is% #aterial has

#i)rate posterolaterall& #a& 'e $na'le to lie own an e+ten the spine(

The ne+t step in the e+a#ination is o'ser!ation of the spine" hips" an le)s $rin)

%ertain #otions( It is well to re#e#'er that no a!anta)e a%%r$es fro# eter#inin)

how #$%h pain the patient %an tolerate( More i#portant is to eter#ine when an

$ner what %onitions the pain 'e)ins or worsens( O'ser!ation of the patient*s )ait

when he is $naware of 'ein) wat%he #a& is%lose a s$'tle li#p" a pel!i% tilt" a

shortenin) of step" or a stiffness of 'earin)@ini%ati!e of a isin%lination to 'earwei)ht on a painf$l le)( One loo-s for li#itation of #otion while the patient is

stanin)" sittin)" an re%linin)( When stanin)" the #otion of forwar 'enin)

nor#all& pro$%es flattenin) an re!ersal of the l$#'ar loroti% %$r!e an

e+a))eration of the thora%i% %$r!e( With lesions of the l$#'osa%ral re)ion that

in!ol!e the posterior li)a#ents" arti%$lar fa%ets" or sa%rospinalis #$s%les an with

r$pt$re l$#'ar is%s" prote%ti!e refle+es pre!ent fle+ion" whi%h stret%hes these

str$%t$res( As a %onse,$en%e" the sa%rospinalis #$s%les re#ain ta$t an pre!ent

#otion in the l$#'ar part of the spine( 1orwar 'enin) then o%%$rs at the hips an

at the thora%ol$#'ar .$n%tion6 also" the patient 'ens in s$%h a wa& as to a!oi

tensin) the ha#strin) #$s%les an p$ttin) $n$e le!era)e on the pel!is( In thepresen%e of e)enerati!e is% isease" strai)htenin) $p fro# a fle+e position is

perfor#e with iffi%$lt& an is aie to so#e e+tent '& fle+in) the -nees(

Lateral 'enin) is $s$all& less instr$%ti!e than forwar 'enin)( In $nilateral

li)a#ento$s or #$s%$lar strain" 'enin) to the opposite sie a))ra!ates the pain '&

stret%hin) the a#a)e tiss$es( With $nilateral s%iati%a" the patient lists to one sie

an stron)l& resists 'enin) to the opposite sie" an his preferre post$re in

stanin) is with the le) sli)htl& fle+e at the hip an -nee( When the herniate is%

lies lateral to the ner!e root an ispla%es it #eiall&" tension on the root is re$%e

'& 'enin) the tr$n- to the sie opposite the lesion6 with herniation #eial to the

root" tension is re$%e '& in%linin) the tr$n- to the sie of the lesion(

In the sittin) position" fle+ion of the spine %an 'e perfor#e #ore easil&" e!en to

the point of 'rin)in) the -nees in %onta%t with the %hest( The reason for this is that

-nee fle+ion rela+es ti)htene ha#strin) #$s%les an relie!es the stret%h on the

s%iati% ner!e( As-in) the seate patient to e+ten the le) so that the sole of the foot

%an 'e inspe%te is a wa& of %he%-in) for a fei)ne Las)$e si)n /see 'elow0(


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E+a#ination in the re%linin) position &iels #$%h the sa#e infor#ation as in the

stanin) an sittin) positions( With l$#'osa%ral is% lesions an s%iati%a" passi!e

l$#'ar fle+ion %a$ses little pain an is not li#ite as lon) as the ha#strin)s are

rela+e an there is no stret%hin) of the s%iati% ner!e( Th$s" with the -nees fle+e

to F8 e)rees" sittin) $p fro# the re%linin) position is $ni#pee an not painf$l6

with -nees e+tene" there is pain an li#ite #otion /Kra$s3We'er test0( With!erte'ral isease /e()(" arthritis0" passi!e fle+ion of the hips is free" whereas fle+ion

of the l$#'ar spine #a& 'e i#pee an painf$l(

Passi!e strai)ht3le) raisin) /possi'le $p to F8 e)rees in nor#al ini!i$als0" li-e

forwar 'enin) in the stanin) post$re with the le)s strai)ht" pla%es the s%iati%

ner!e an its roots $ner tension" there'& pro$%in) rai%$lar raiatin) pain( It #a&

also %a$se an anterior rotation of the pel!is aro$n a trans!erse a+is" in%reasin)

stress on the l$#'osa%ral .oint an %a$sin) pain if this .oint is arthriti% or otherwise

isease( Conse,$entl&" in iseases of the l$#'osa%ral .oints an roots" passi!e

strai)ht3le) raisin) e!o-es pain an is li#ite on the affe%te sie an" to a lesser

e+tent" on the opposite sie /Las)$e si)n0( Strai)ht raisin) of the opposite le) #a&also %a$se pain on the affe%te sie an is 'elie!e '& so#e to 'e an e!en #ore

relia'le si)n of prolapse is% than a Las)$e si)n( It is i#portant to re#e#'er that

the e!o-e pain is alwa&s referre to the isease sie" no #atter whi%h le) is

ele!ate( While in the s$pine position" le) len)th /anteros$perior ilia% spine to

#eial #alleol$s0 an the %ir%$#feren%e of the thi)h an %alf sho$l 'e #eas$re(

H&pere+tension #a& 'e perfor#e with the patient stanin) or l&in) prone( If the

%onition %a$sin) 'a%- pain is a%$te" it #a& 'e iffi%$lt to e+ten the spine in the

stanin) position( A patient with l$#'osa%ral strain or is% isease /e+%ept in the

a%$te phase or if the is% fra)#ent has #i)rate laterall&0 %an $s$all& e+ten or

h&pere+ten the spine with little or no a))ra!ation of pain( If there is an a%ti!e

infla##ator& pro%ess or fra%t$re of the !erte'ral 'o& or posterior ele#ents"

h&pere+tension #a& 'e #ar-el& li#ite( In isease of the $pper l$#'ar roots"

h&pere+tension is the #otion that is li#ite an repro$%es pain6 howe!er" in so#e

%ases of lower l$#'ar is% isease with thi%-enin) of the li)a#ent$# fla!$#" this

#o!e#ent is also painf$l( In patients with narrowin) of the spinal %anal

/spon&losis" spon&lolisthesis0" $pri)ht stan%e an e+tension #a& pro$%e

ne$rolo)i% spto#s /see f$rther on0(

Mane$!ers in the lateral e%$'it$s position &iel less infor#ation as a r$le( In %ases

of sa%roilia% .oint isease" a'$%tion of the $psie le) a)ainst resistan%e repro$%espain in the sa%roilia% re)ion" with raiation of the pain to the '$tto%-" posterior

thi)h" an sph&sis p$'is( H&pere+tension of the $psie le) with the ownsie le)

fle+e is another test for sa%roilia% isease( Rotation an a'$%tion of the le) e!o-e

pain in a isease hip .oint an with tro%hanteri% '$rsitis( Another helpf$l ini%ator

of hip pain is the Patri%- test; with the patient s$pine" the heel of the offenin) le)

is pla%e on the opposite -nee an pain is e!o-e '& epressin) the fle+e le) an

e+ternall& rotatin) the hip(


8/29

:entle palpation an per%$ssion of the spine are the last steps in the e+a#ination(

It is prefera'le to first palpate the re)ions that are the least li-el& to e!o-e pain( At

all ti#es the e+a#iner sho$l -now what str$%t$res are 'ein) palpate /see 1i)( 223

G0( Lo%ali=e tenerness is selo# prono$n%e in isease of the spine 'e%a$se the

in!ol!e str$%t$res are so eep( Ne!ertheless" tenerness o!er a spino$s pro%ess or

.arrin) '& )entle per%$ssion #a& ini%ate the presen%e of infla##ation /as in is%spa%e infe%tion0" patholo)i% fra%t$re" a spinal #etastasis" or a is% lesion at the site

eep to it(

1i)$re 223G /20 Costo!erte'ral an)le( /40 Spino$s pro%ess an interspino$s li)a#ent(/G0 Re)ion of arti%$lar fa%et /fifth l$#'ar to first sa%ral0( /0 Dors$# of sa%r$#( /0

Re)ion of ilia% %rest( /0 Iliol$#'ar an)le( /70 Spino$s pro%esses of fifth l$#'ar an

first sa%ral !erte'rae /tenerness fa$lt& post$re or o%%asionall& spina 'ifia

o%%$lta0( /0 Re)ion 'etween posterior s$perior an posterior inferior spines(

Sa%roilia% li)a#ents /tenerness sa%roilia% sprain" often tener with fifth l$#'ar

or first sa%ral is%0( /F0 Sa%ro%o%%&)eal .$n%tion /tenerness sa%ro%o%%&)eal

in.$r&" i(e(" sprain or fra%t$re0( /280 Re)ion of sa%ros%iati% not%h /tenerness

fo$rth or fifth l$#'ar is% r$pt$re an sa%roilia% sprain0( /220 S%iati% ner!e tr$n-

/tenerness r$pt$re l$#'ar is% or s%iati% ner!e lesion0(

Tenerness o!er the %osto!erte'ral an)le often ini%ates )enito$rinar& isease"

arenal isease" or an in.$r& to the trans!erse pro%ess of the first or se%on l$#'ar

!erte'ra 1i)( 223G" /20J( Tenerness on palpation of the paraspinal #$s%les #a&

si)nif& a strain of #$s%le atta%h#ents or in.$r& to the $nerl&in) trans!erse

pro%esses of the l$#'ar !erte'rae( 1o%al pain in the sa#e sa)ittal line alon) the

thora%i% spine points to infla##ation of the %ostotrans!erse arti%$lation 'etween

spine an ri' /%ostotrans!ersitis0(

In palpatin) the spino$s pro%esses" it is i#portant to note an& e!iation in the

lateral plane /this #a& 'e ini%ati!e of fra%t$re or arthritis0 or in the anteroposterior

plane( A >step3off? forwar ispla%e#ent of the spino$s pro%ess an e+a))erate

lorosis are i#portant %l$es to the presen%e of spon&lolisthesis /see f$rther on0(

Tenerness o!er the interspino$s li)a#ents is ini%ati!e of is% lesions 1i)( 223G"

/40J( Tenerness o!er the re)ion of the arti%$lar fa%ets 'etween the fifth l$#'ar an

first sa%ral !erte'rae is %onsistent with l$#'osa%ral is% isease 1i)( 223G" /G0J(


9/29


10/29

$sef$l onl& in the %onte+t of the histor& an %lini%al e+a#ination6 otherwise the& are

s$'.e%t to o!er$se an o!erinterpretation(

Prin%ipal Conitions :i!in) Rise to Pain in the Lower Ba%-

Con)enital Ano#alies of the L$#'ar Spine Anato#i% !ariations of the spine are

fre,$ent" an tho$)h rarel& of the#sel!es the so$r%e of pain an f$n%tional

eran)e#ent" the& #a& preispose an ini!i$al to is%o)eni% an spon&loti%

%o#pli%ations '& !irt$e of alterin) the #e%hani%s an ali)n#ent of the !erte'rae or

si=e of the spinal %anal(

The %o##onest ano#al& is a la%- of f$sion of the la#inae of one or se!eral of the

l$#'ar !erte'rae or of the sa%r$# /spina 'ifia0( O%%asionall&" a s$'%$taneo$s

#ass" h&pertri%hosis" or h&perpi)#entation in the sa%ral area 'etra&s the %onition"

'$t in #ost patients it re#ains o%%$lt $ntil it is is%lose raiolo)i%all&( The ano#al&

#a& 'e a%%o#panie '& #alfor#ation of !erte'ral .oints an $s$all& in$%es pain

onl& when a))ra!ate '& in.$r&( The ne$rolo)i% aspe%ts of efe%ti!e f$sion of the

spine /&sraphis#0 are is%$sse in Chap( G(

Man& other %on)enital ano#alies affe%t the lower l$#'ar !erte'rae; as#etri%al

fa%etal .oints" a'nor#alities of the trans!erse pro%esses" >sa%rali=ation? of the fifth

l$#'ar !erte'ra /in whi%h L appears to 'e fi+e to the sa%r$#0" or >l$#'ari=ation?

of the first sa%ral !erte'ra /in whi%h S2 loo-s li-e a si+th l$#'ar !erte'ra0 are seen

o%%asionall& in patients with low 'a%- spto#s" '$t apparentl& with no )reater

fre,$en%& than in aspto#ati% ini!i$als( The role of these ano#alies in the

)enesis of low 'a%- eran)e#ent is $n%lear" '$t in the a$thors* opinion the& are

rarel& the %a$se of spe%ifi% spto#s(

Spon&lol&sis %onsists of a 'on& efe%t in the pars interarti%$laris /the se)#ent at

the .$n%tion of pei%le an la#ina0 of the lower l$#'ar !erte'rae( The efe%t is

re#ar-a'l& %o##on6 it affe%ts appro+i#atel& per%ent of the North A#eri%an

pop$lation" is pro'a'l& )eneti%" an preisposes to fra%t$re at this lo%ation(

Raio)raphi%all&" the pars interarti%$laris efe%t is 'est !is$ali=e on o'li,$e

pro.e%tions( In so#e persons it is $nilateral an #a& %a$se $nilateral a%hin) 'a%-

pain that is a%%ent$ate '& h&pere+tension an twistin)( It is not $n%o##on in

athletes( In the $s$al 'ilateral for#" s#all fra%t$res at the pars interarti%$laris allow

the !erte'ral 'o&" pei%les" an s$perior arti%$lar fa%ets to #o!e anteriorl&"

lea!in) the posterior ele#ents 'ehin( This latter efor#it&" -nown as

spon&lolisthesis" is #ainl& a isease of %hilren /pea- in%ien%e 'etween an 7&ears of a)e0( It #a& %a$se little iffi%$lt& at first '$t e!ent$all& 'e%o#es

spto#ati%( The patient %o#plains of li#itation of #otion an pain in the low

'a%-" raiatin) into the thi)hs( E+a#ination is%loses tenerness near the se)#ent

that has >slippe? /#ost often L" o%%asionall& L0" a palpa'le >step? of the spino$s

pro%ess forwar fro# the se)#ent 'elow" ha#strin) spas#" an" in se!ere %ases

/spon&loptosis0" shortenin) of the tr$n- an protr$sion of the lower a'o#en /'oth


11/29

of whi%h res$lt fro# the a'nor#al forwar shift of L on S20 as well as si)ns of

in!ol!e#ent of spinal roots@paresthesias an sensor& loss" #$s%le wea-ness" an

refle+ i#pair#ent( These ne$rolo)i% spto#s an si)ns ten not to 'e se!ere(

So#eti#es" the fo$rth l$#'ar !erte'ra #a& slip forwar on the fifth" narrowin) the

spinal %anal" witho$t the presen%e of a efe%t in the pars interarti%$laris( This ister#e inta%t ar%h spon&lolisthesis an o%%$rs #ost often in #ile3a)e or

elerl& wo#en( This for# of spon&lolisthesis is pro'a'l& $e to e)enerati!e

isease of the inferior an s$perior fa%ets( It %a$ses se!ere low 'a%- pain" #ae

worse '& stanin) or wal-in) an relie!e '& 'e rest( Spto#s of root

%o#pression are %o##on /Ale+aner et al0(

Patients with pro)ressi!e !erte'ral ispla%e#ent an ne$rolo)i% efi%its re,$ire

s$r)er&" $s$all& posterolateral f$sion an e+%ision of the posterior ele#ents(

Re$%tion of ispla%e !erte'ral 'oies 'efore f$sion an ire%t repair of pars

efe%ts are possi'le in spe%ial %ases(

Tra$#ati% Disorers of the Low Ba%- Tra$#ati% isorers %onstit$te the #ost

fre,$ent %a$se of low 'a%- pain( In se!ere a%$te in.$ries" the e+a#iner #$st 'e

%aref$l to a!oi f$rther a#a)e( All #o!e#ents #$st 'e -ept to a #ini#$# $ntil an

appro+i#ate ia)nosis has 'een #ae an ae,$ate #eas$res ha!e 'een

instit$te for the proper %are of the patient( If the patient %o#plains of pain in the

'a%- an %annot #o!e his le)s" the spine #a& ha!e 'een fra%t$re an the %or or

%a$a e,$ina %o#presse or %r$she( The ne%- sho$l not 'e #anip$late" an the

patient sho$l not 'e allowe to sit $p( /See Chap( for f$rther is%$ssion of spinal

%or in.$r&(0

Sprains an Strains The ter#s l$#'osa%ral strain" sprain" an eran)e#ent are$se loosel& '& #ost ph&si%ians" an it is pro'a'l& not possi'le to ifferentiate

the#( What was for#erl& referre to as >sa%roilia% strain? or >sprain? is now -nown

to 'e $e" in #an& instan%es" to is% isease( The a$thors prefer the ter# a%$te low

'a%- or #&ofas%ial strain for #inor" self3li#ite in.$ries that are $s$all& asso%iate

with liftin) hea!& loas in a #e%hani%all& isa!anta)e position" a fall" stiffness

that arises fro# prolon)e $n%o#forta'le post$res s$%h as air tra!el or %ar ries" or

s$en $ne+pe%te #otion" as #a& o%%$r in an a$to a%%ient(

The is%o#fort of a%$te low3'a%- strain is often se!ere" an the patient #a&

ass$#e $n$s$al post$res relate to spas# of the lower l$#'ar an sa%rospinalis

#$s%les( The pain is $s$all& %onfine to the lower part of the 'a%-" in the #iline or.$st to one sie or other of the spine( The ia)nosis of l$#'osa%ral strain epens

$pon the es%ription of the in.$r& or a%ti!it& that pre%ipitate the pain" the

lo%ali=ation of the pain" the finin) of lo%ali=e tenerness" the a$)#entation of

pain '& post$ral %han)es" e()(" 'enin) forwar" twistin)" or stanin) $p fro# a

sittin) position" an the a'sen%e of si)ns of rai%$lar in!ol!e#ent( In #ore than 8


12/29

per%ent of %ases of a%$te low3'a%- strain of this t&pe" the pain resol!es in a #atter

of se!eral a&s or a wee- e!en with no spe%ifi% treat#ent(

Sa%roilia% strain is the #ost li-el& ia)nosis when there is tenerness o!er the

sa%roilia% .oint an pain raiatin) to the '$tto%- an posterior thi)h" '$t this alwa&s

nees to 'e istin)$ishe fro# a r$pt$re inter!erte'ral is% /see f$rther on0( Strainis %hara%teristi%all& worsene '& a'$%tion of the thi)h a)ainst resistan%e an is

also felt in the sph&sis p$'is or )roin( It" too" respons within a&s or a wee- or

two to %onser!ati!e #ana)e#ent(

Treat#ent of A%$te Low3Ba%- Strains The pain of #$s%$lar an li)a#ento$s strains

is $s$all& self3li#ite" responin) to si#ple #eas$res in a relati!el& short perio of

ti#e( The 'asi% prin%iple of therap& in 'oth isorers is rest" in a re%$#'ent

position" for se!eral a&s( L&in) on the sie with -nees an hips fle+e or s$pine

with a pillow $ner the -nees are the fa!ore positions( With strains of the

sa%rospinalis #$s%les an sa%roilia% li)a#ents" the opti#al position is

h&pere+tension( This position is 'est #aintaine '& ha!in) the patient lie with as#all pillow or fole 'lan-et $ner the l$#'ar portion of the spine or '& l&in) fa%e

own( Ph&si%al #eas$res@s$%h as appli%ation of i%e in the a%$te phase /G8 #in on"

8 #in off0 an heat after the thir or fo$rth a&" iather#&" an #assa)e@%an 'e

trie '$t are of li#ite !al$e( Nonsteroial anti3infla##ator& #ei%ation sho$l 'e

)i!en li'erall& $rin) the first few a&s( M$s%le rela+ants are of little $se" ser!in)

#ainl& to #a-e 'e rest #ore tolera'le( When wei)ht 'earin) is res$#e"

is%o#fort #a& 'e i#inishe '& a li)ht l$#'osa%ral s$pport" '$t #an&

orthopeists refrain fro# pres%ri'in) this ai( Thereafter" %orre%ti!e e+er%ises are

pres%ri'e" esi)ne to stret%h an stren)then tr$n- /espe%iall& a'o#inal0

#$s%les" o!er%o#e fa$lt& post$re" an in%rease the #o'ilit& of the spinal .oints(

The $se of spinal #anip$lation@pra%ti%e '& %hiropra%tors" osteopaths" an others

@has alwa&s 'een a %ontentio$s #atter in the


13/29

en of a #onth( Despite se!eral h&potheses that ha!e 'een offere '& pra%titioners

of spinal #anip$lation" the #e%hanis# of pain relief is not -nown( The so$n

%reate '& rapi an for%ef$l istra%tion of the fa%et .oints" si#ilar to %ra%-in) the

-n$%-les" see#s not to 'e ne%essar& for pain relief( Whether all for#s of low3'a%-

pain represent #inor s$'l$+ations" as %lai#e '& %hiropra%tors" is $no%$#ente

an see#s $nli-el&( Chroni% low 'a%- pain has" in the a$thors* e+perien%e" 'eene!en less s$%%essf$ll& treate '& #anip$lati!e pro%e$res" '$t there are patients

who testif& to i#pro!e#ent in their %lini%al state" an a#ittel& the #ei%al

profession has little to offer #an& of these patients( The %o##it#ent of patients to

a re)i#e of anti3infla##ator& a)ents for #an& #onths or to nar%oti% anal)esi%s is a

ha=ar alwa&s to 'e a!oie(

The De)enerati!e Low3Ba%- S&nro#e Often the spto#s of low3'a%- strain are

re%$rrent an #ore %hroni% in nat$re" 'ein) re)$larl& e+a%er'ate '& 'enin) or

liftin)" s$))estin) that post$ral" #$s%$lar" an arthriti% fa%tors pla& a role( This is

the #ost %o##on s&nro#e seen in orthopei% %lini%s" #ore in #en than in

wo#en(

After so#e $n$s$al a%ti!it&" raisin) the ,$estion of tra$#a" espe%iall& if it happens

in the wor-pla%e" the patient e!elops eep a%hin) pain in the low 'a%-" in%rease

'& %ertain #o!e#ents an attene '& stiffness( The pain often has a restri%te

raiation into the '$tto%-s an posterior thi)h( There are no #otor" sensor&" or

refle+ a'nor#alities( Plain fil#s an i#a)in) pro%e$res re!eal so#e %o#'ination

of osteoarthropath&" %han)es in !erte'ral is%s" osteoarthriti% %han)es in

apoph&seal .oints" an so#eti#es osteoporosis or sli)ht spon&losis( Treat#ent

with short3$ration 'e rest" anal)esi%s" an ph&siotherap&" as o$tline for a%$te

strains" help to relie!e the spto#s an the #a.orit& of patients re%o!er within a

#onth( Chiropra%ti% #anip$lation has the sa#e $n%ertain effe%t as for a%$te low3

'a%- spto#s( '$rst? fra%t$re of one or #ore !erte'ral 'oies" or an as#etri%alfra%t$re of a pei%le" la#ina" or spino$s pro%ess" '$t #ost often there is

as#etri%al loss of hei)ht of a !erte'ral 'o& /%o#pression fra%t$re0" whi%h #a&

'e e+tre#el& painf$l at the onset( When %o#pression or other fra%t$res o%%$r with

#ini#al tra$#a /or spontaneo$sl&0" the 'one has pres$#a'l& 'een wea-ene '&

so#e patholo)i% pro%ess( Most of the ti#e" parti%$larl& in oler ini!i$als"

osteoporosis is the %a$se of s$%h an e!ent" '$t there are #an& other %a$ses" in%l$3

in) osteo#ala%ia" h&perparath&roiis#" prolon)e $se of %orti%osterois" an-&losin)


14/29

spon&litis" #&elo#a" #etastati% %ar%ino#a" an a n$#'er of lo%al %onitions(

Spas# of the lower l$#'ar #$s%les" li#itation of all #o!e#ents of the l$#'ar

se%tion of the spine" an the raio)raphi% appearan%e of the a#a)e l$#'ar

portion /with or witho$t ne$rolo)i% a'nor#alities0 are the 'asis of %lini%al ia)nosis(

The pain is $s$all& i##eiate" tho$)h o%%asionall& it #a& 'e ela&e for a&s(

A fra%t$re trans!erse pro%ess" whi%h is al#ost alwa&s asso%iate with tearin) of

the para!erte'ral #$s%les an a lo%al he#ato#a" %a$ses eep tenerness at the

site of the in.$r&" lo%al #$s%le spas#" an li#itation of all #o!e#ents that stret%h

the l$#'ar #$s%les( The raiolo)i% finin)s" parti%$larl& MRI" %onfir# the ia)nosis(

In so#e %ir%$#stan%es" tears of the para!erte'ral #$s%$lat$re #a& 'e asso%iate

with e+tensi!e 'leein) into the retroperitoneal spa%e an pro+i#al le) wea-ness(

Herniation of L$#'ar Inter!erte'ral Dis%s This %onition is a #a.or %a$se of se!ere

an %hroni% or re%$rrent low 'a%- an le) pain( It o%%$rs #ainl& $rin) the thir an

fo$rth e%aes of life" when the n$%le$s p$lpos$s is still )elatino$s( The is%

'etween the fifth l$#'ar an first sa%ral !erte'rae /L3S20 is the one #ost oftenin!ol!e" an" with e%reasin) fre,$en%&" that 'etween the fo$rth an fifth /L30"

thir an fo$rth /LG30" se%on an thir /L43G0" an ,$ite infre,$entl&" the first an

se%on /L2340 l$#'ar !erte'rae( Relati!el& rare '$t well es%ri'e in the thora%i%

portion of the spine" is% isease is a)ain fre,$ent at the fifth an si+th an the

si+th an se!enth %er!i%al !erte'rae /see f$rther on0(

The %a$se of a herniate l$#'ar is% is $s$all& a fle+ion in.$r&" '$t a %onsiera'le

proportion of patients o not re%all a tra$#ati% episoe( De)eneration of the

n$%le$s p$lpos$s" the posterior lon)it$inal li)a#ents" an the ann$l$s fi'ros$s

#a& ha!e ta-en pla%e silentl& or ha!e 'een #anifest '& #il" re%$rrent l$#'ar

a%he( A snee=e" l$r%h" or other tri!ial #o!e#ent #a& then %a$se the n$%le$sp$lpos$s to prolapse" p$shin) the fra&e an wea-ene ann$l$s posteriorl&(

1ra)#ents of the n$%le$s p$lpos$s protr$e thro$)h rents in the ann$l$s" $s$all& to

one sie or the other /so#eti#es in the #iline0" where the& i#pin)e $pon a root or

roots( In #ore se!ere %ases of is% isease" the n$%le$s #a& protr$e thro$)h the

ann$l$s or 'e e+tr$e an lie epi$rall&" as a free fra)#ent( A lar)e protr$sion

#a& %o#press the root/s0 a)ainst the arti%$lar apoph&sis or la#ina( The protr$e

#aterial #a& 'e resor'e to so#e e+tent an 'e%o#e re$%e in si=e" '$t often it

oes not" %a$sin) %hroni% irritation of the root or a is%arthrosis with posterior

osteoph&te for#ation(

The Clini%al S&nro#e The f$ll& e!elope s&nro#e of prolapse inter!erte'ral

l$#'ar is% %onsists of; /20 pain in the sa%roilia% re)ion" raiatin) into the '$tto%-"

thi)h" %alf" an foot an 'roal& ter#e s%iati%a6 /40 a stiff or $nnat$ral spinal

post$re6 an /G0 so#e %o#'ination of paresthesias" wea-ness" an refle+

i#pair#ent(


15/29

The pain of herniate inter!erte'ral is% !aries in se!erit& fro# a #il is%o#fort to

the #ost se!ere -nife3li-e sta's that raiate the len)th of the le) an are

s$peri#pose on a %onstant intense a%he( A'orti!e for#s of s%iati%a #a& pro$%e

a%hin) is%o#fort onl& in the lower '$tto%- an thi)h an o%%asionall& onl& in the

lower ha#strin) or $pper %alf( With the #ost se!ere pain" the patient is for%e to

sta& in 'e" a!oiin) the sli)htest #o!e#ent6 a %o$)h" snee=e" or strain isintolera'le( The patient is $s$all& #ost %o#forta'le l&in) on his 'a%- with le)s

fle+e at the -nees an hips /orsal e%$'it$s position0 an with the sho$lers

raise on pillows to o'literate the l$#'ar lorosis( 1or so#e patients" a parti%$lar

lateral e%$'it$s position is #ore %o#forta'le( As #entione earlier" free fra)#ents

of is% that fin their wa& to a lateral an posterior position in the spinal %anal #a&

pro$%e the opposite sit$ation" one of 'ein) $na'le to e+ten the spine an lie

s$pine( When the %onition is less se!ere" wal-in) is possi'le" tho$)h fati)$e sets in

,$i%-l&" with a feelin) of hea!iness an rawin) pain( Sittin) an stanin) $p fro# a

sittin) position are parti%$larl& painf$l( The pain is $s$all& lo%ate eep in the

'$tto%-" .$st lateral to an 'elow the sa%roilia% .oint" an in the posterolateral

re)ion of the thi)h" with raiation to the %alf an infre,$entl& to the heel an other

parts of the foot( Raiation of pain into the foot sho$l at least raise the s$spi%ion of

an alternati!e %a$se of ner!e a#a)e( It is noteworth& an s$rprisin) to patients

that a l$#'ar is% protr$sion so#eti#es %a$ses little 'a%- pain" altho$)h in these

%ir%$#stan%es there is often" in o$r e+perien%e" eep tenerness o!er the lateral

pro%ess or fa%et .oint a.a%ent to the protr$sion( Pain is also %hara%teristi%all&

pro!o-e '& press$re o!er the %o$rse of the s%iati% ner!e at the %lassi% points of

allei+ /s%iati% not%h" retrotro%hanteri% )$tter" posterior s$rfa%e of thi)h" hea of

fi'$la0( Press$re at one point #a& %a$se raiation of pain an tin)lin) own the le)(

Elon)ation of the ner!e root '& strai)ht3le) raisin) or '& fle+in) the le) at the hipan e+tenin) it at the -nee /Las)$e #ane$!er0 is the #ost %onsistent of all pain3

pro!o-in) si)ns( When s%iati%a is se!ere" strai)ht3le) raisin) is restri%te to 48 to G8

e)rees of ele!ation6 when the %onition is less se!ere or with i#pro!e#ent" the

an)le for#e '& the le) an 'e wiens" finall& to al#ost F8 e)rees" in patients

with fle+i'le 'a%-s an li#'s( D$rin) strai)ht3le) raisin)" the patient %an istin)$ish

'etween the is%o#fort of orinar& ta$tness of the ha#strin) an the sharper" less

fa#iliar root pain" parti%$larl& when as-e to %o#pare the e+perien%e with that on

the nor#al sie( Man& !ariations of the Las)$e #ane$!er ha!e 'een es%ri'e /all

with epons0" the #ost $sef$l of whi%h is a%%ent$ation of the pain '& orsifle+ion

of the foot /Bra)ar si)n0 or of the )reat toe /Si%ar si)n0( The Las)$e #ane$!er

with the health& le) #a& e!o-e pain" '$t $s$all& of lesser e)ree an alwa&s on the

sie of the spontaneo$s pain /1a.ersta)n si)n0( The presen%e of a %rosse strai)ht3

le)3raisin) si)n is stron)l& ini%ati!e of a r$pt$re is% as the %a$se of s%iati%a /in

of %ases in the series of H$)-ins0( With the patient stanin)" forwar

'enin) of the tr$n- will %a$se fle+ion of the -nee on the affe%te sie /Neri si)n06

the e)ree of li#itation of forwar 'enin) appro+i#ates that of strai)ht3le)

raisin)( S%iati%a #a& 'e pro!o-e '& for%e fle+ion of the hea an ne%-" %o$)hin)"


16/29

or press$re on 'oth .$)$lar !eins" all of whi%h in%rease the intraspinal press$re

/Naff=i)er si)n0( Mar-e in%onsisten%ies in response to these tests raise the

s$spi%ion of ps&%holo)i% fa%tors(

In the $pri)ht position" the post$re of the 'o& is altere '& the pain( The patient

stans with the affe%te le) sli)htl& fle+e at the -nee an hip" so that onl& the 'allof the foot rests on the floor( The tr$n- tens to tilt forwar an to one sie or the

other" epenin) on the relationship of the protr$e is% #aterial to the root /see

a'o!e0( This antal)i% post$re is referre to as s%iati% s%oliosis an is #aintaine '&

refle+ %ontra%tion of the paraspinal #$s%les" whi%h %an 'e 'oth seen an palpate(

In wal-in)" the -nee is sli)htl& fle+e" an wei)ht 'earin) on the painf$l le) is 'rief

an %a$tio$s" )i!in) a li#p( It is parti%$larl& painf$l for the patient to )o $p an

own stairs(

The si)ns of se!ere spinal root %o#pression are i#pair#ent of sensation" loss or

i#in$tion of tenon refle+es" an #$s%le wea-ness( The h&potonia is e!ient on

inspe%tion an palpation of the '$tto%- an %alf" an the A%hilles tenon tens to 'eless salient( Paresthesias /rarel& h&peresthesia or h&poesthesia0 are reporte '&

one3thir of patients6 $s$all& the& are felt in the foot" so#eti#es in the le)( Often

there is a i#in$tion of pain per%eption o!er the appropriate er#ato#e( M$s%le

wea-ness o%%$rs" '$t less fre,$entl&( The an-le or -nee .er- is $s$all& i#inishe or

lost on the sie of the lesion( The refle+ %han)es ha!e little relationship to the

se!erit& of the pain or sensor& loss( 1$rther#ore" %o#pression of the fo$rth or fifth

l$#'ar root #a& o%%$r witho$t an& %han)e in the tenon refle+es( Bilateralit& of

spto#s an si)ns is rare" as is sphin%teri% paral&sis" '$t the& #a& o%%$r with

lar)e %entral protr$sions( The %ere'rospinal fl$i /CS10 protein is then prei%ta'l&

ele!ate" $s$all& in the ran)e of to #)L" so#eti#es hi)her(

As ini%ate a'o!e" herniations of the inter!erte'ral l$#'ar is%s o%%$r #ost often

'etween the fifth l$#'ar an first sa%ral !erte'rae /%o#pressin) the S2 root6 see

1i) 2230 an 'etween the fo$rth an fifth l$#'ar !erte'rae /%o#pressin) the L

root0( It is i#portant" therefore" to re%o)ni=e the %lini%al %hara%teristi%s of root

%o#pression at these two sites( Lesions of the fifth l$#'ar root pro$%e pain in the

re)ion of the hip" posterolateral thi)h" lateral %alf /to the e+ternal #alleol$s0" orsal

s$rfa%e of the foot" an the first or se%on an thir toes( Paresthesias #a& 'e felt

in the entire territor& or onl& in its istal parts( The tenerness is in the lateral

)l$teal re)ion an near the hea of the fe#$r( Wea-ness" if present" in!ol!es the

e+tensors of the 'i) toe an of the foot( The an-le .er- #a& 'e i#inishe /#oreoften it is nor#al0" '$t the -nee .er- is harl& e!er altere( Wal-in) on the heels

#a& 'e #ore iffi%$lt an $n%o#forta'le than wal-in) on the toes 'e%a$se of

wea-ness of orsifle+ion(


17/29

1i)$re 223 Me%hanis#s of %o#pression of the fifth l$#'ar an first sa%ral roots( A

lateral is% protr$sion at the L3 le!el $s$all& in!ol!es the fifth l$#'ar root an

spares the fo$rth6 a protr$sion at L3S2 in!ol!es the first sa%ral root an spares the

fifth l$#'ar root( Note that a #ore #eiall& pla%e is% protr$sion at the L3 le!el

/%ross3hat%he0 #a& in!ol!e the fifth l$#'ar root as well as the first /or se%on an

thir0 sa%ral root(

With lesions of the first sa%ral root" the pain is felt in the #i)l$teal re)ion" posterior

part of the thi)h" posterior re)ion of the %alf to the heel" o$ter plantar s$rfa%e of the

foot" an fo$rth an fifth toes( Tenerness is #ost prono$n%e o!er the #i)l$tealre)ion /in the re)ion of the sa%roilia% .oint0" posterior thi)h areas" an %alf(

Paresthesias an sensor& loss are #ainl& in the lower part of the le) an o$ter toes"

an wea-ness" if present" in!ol!es the fle+or #$s%les of the foot an toes"

a'$%tors of the toes" an ha#strin) #$s%les( The A%hilles refle+ is i#inishe or

a'sent in the #a.orit& of %ases( In fa%t" loss of the A%hilles refle+ is often the first

an onl& o'.e%ti!e si)n( Wal-in) on the toes is #ore iffi%$lt an $n%o#forta'le

than wal-in) on the heels 'e%a$se of wea-ness of the plantar fle+ors(

The rarer lesions of the thir an fo$rth l$#'ar roots )i!e rise to pain in the anterior

part of the thi)h an -nee an antero#eial part of the le) /fo$rth l$#'ar0" with

%orresponin) sensor& i#pair#ent( The -nee .er- is i#inishe or a'olishe( LG#otor root lesions #a& wea-en the ,$ari%eps" thi)h a$%tor" an iliopsoas6 L

root lesions wea-en the anterior ti'ial inner!ate #$s%les( L2 root pain is pro.e%te

to the )roin an L4 to the lateral hip( Motion of the spine an %ertain positions are

#ost e!o%ati!e of root pain6 if the pain is %onstant in all positions" root irritation is

selo# the %a$se(

M$%h has 'een #ae of a istin%ti!e s&nro#e asso%iate with e+tre#e lateral is%

protr$sions" parti%$larl& those l&in) within the pro+i#al portion of the inter!erte'ral

spinal fora#ina(


18/29


19/29

1i)$re 223 L$#'ar is% herniation on T32 wei)hte MRI( A( Sa)ittal !iew of lar)e

L3S2 herniate n$%le$s p$lposis /arrow0( The e+tr$e #aterial has the sa#e

si)nal %hara%teristi%s as the nor#al a.a%ent is%( B( A+ial !iew of sa#e is% /arrow0

showin) the para%entral #ass that o'literates the epi$ral fat si)nal an

%o#presses the S2 root(

It is #ost i#portant to -eep in #in that a n$#'er of is% a'nor#alities" fre,$entl&

o'ser!e on MRI an loosel& referre to as >herniation"? #a& 'e in%iental finin)s"

$nrelate to the patient*s spto#s( 9ensen an %ollea)$es" in an MRI st$& of the

l$#'ar spine in F aspto#ati% a$lts" fo$n that in #ore than half of the# there

was a s#etri%al e+tension of a is% /or is%s0 'e&on the #ar)ins of the

interspa%e /'$l)in)0( In 47 per%ent" there was a fo%al or as#etri%al e+tension of

the is% 'e&on the interspa%e /protr$sion0" an in onl& 2 per%ent was there #ore

e+tre#e e+tension of the is% /e+tr$sion0( These finin)s e#phasi=e the i#portan%e

of $sin) pre%ise #orpholo)i% ter#s in es%ri'in) the MRI a'nor#alities an alwa&s

e!al$atin) these a'nor#alities in the li)ht of the patient*s spto#s(

Mana)e#ent of R$pt$re L$#'ar Dis% In the treat#ent of an a%$te or %hroni%

r$pt$re of a l$#'ar is%" %o#plete 'e rest is $s$all& a!ise an appears to 'e

helpf$l" altho$)h e!en this ti#e3honore tenet has 'een ,$estione '& the res$lts

of a rano#i=e st$& /roo#en et al0( Nonetheless we ahere to this for# of

treat#ent an it res$lts in #ar-e i#pro!e#ent in o!er 8 per%ent of patients(

Anal)esi% #ei%ation" either nonsteroial anti3infla##ator& a)ents or nar%oti%s"

#a& 'e re,$ire for a few a&s( In so#e patients with se!ere s%iati%a" we ha!e

'een i#presse with the relief affore '& a#inistration of oral e+a#ethasone

for se!eral a&s" #) e!er& h" altho$)h this has not 'een st$ie s&ste#ati%all&(

The onl& ini%ation for e#er)en%& s$r)er& is an a%$te %o#pression of the %a$a

e,$ina '& #assi!e is% e+tr$sion" %a$sin) 'ilateral sensori#otor loss ansphin%teri% paral&sis or se!ere $nilateral #otor loss( Altho$)h not the

re%o##ene %o$rse for #ost patients" it sho$l 'e pointe o$t that there are

instan%es where e!en a ra#ati% s&nro#e of %a$a e,$ina %o#pression has

%leare $p after se!eral wee-s of 'e rest( Tra%tion is of little !al$e in l$#'ar is%

isease" an it is 'est to per#it the patient to fin the #ost %o#forta'le position(

After 2 or 4 wee-s at rest" the patient %an 'e allowe to res$#e a%ti!ities )ra$all&"


20/29

so#eti#es with the prote%tion of a 'ra%e or li)ht spinal s$pport( The patient #a&

s$ffer #inor re%$rren%e of the pain '$t sho$l 'e a'le to %ontin$e his $s$al

a%ti!ities an e!ent$all& will re%o!er(

If the pain an ne$rolo)i% finin)s o not s$'sie in response to this t&pe of

%onser!ati!e #ana)e#ent or the patient s$ffers fre,$ent isa'lin) a%$te episoes"s$r)i%al treat#ent #$st 'e %onsiere( This sho$l 'e pre%ee '& CT3

#&eolo)raph& or MRI to lo%ali=e the lesion /an e+%l$e intra3 or e+tra$ral

t$#ors0( The s$r)i%al pro%e$re #ost often ini%ate for l$#'ar is% isease is a

he#ila#ine%to#&" with e+%ision of the is% in!ol!e( In %ases with s%iati% pain $e

to L3 or L3S2 is% r$pt$res" to F8 per%ent are relie!e '& operation( Rer$pt$re

o%%$rs in appro+i#atel& per%ent /Shannon an Pa$l0( Arthroesis /spinal f$sion0 of

the in!ol!e se)#ents is ini%ate onl& in %ases in whi%h there is e+traorinar&

insta'ilit&" $s$all& relate to an anato#i% a'nor#alit& /s$%h as spon&lol&sis0( The

treat#ent of ner!e root %o#pression with repeate epi$ral in.e%tions of

#eth&lprenisolone en.o&e a perio of pop$larit&" '$t %ontrolle st$ies of this

pro%e$re ha!e faile to %onfir# its s$staine effi%a%& /White et al6 C$%-ler et al0an the pro%e$re is not witho$t %o#pli%ations( Carette et al ha!e fo$n onl& short3

ter# i#pro!e#ent with fa%et in.e%tion" '$t the $lti#ate nee for s$r)er& was not

altere /see f$rther on0( Ne!ertheless" #an& ne$rolo)ists ha!e not is%are this

for# of treat#ent in !iew of nota'le s$%%ess in sele%te patients(

Che#on$%leol&sis has 'een $se for the #ana)e#ent of l$#'ar is% lesions6

howe!er" as e+perien%e with this pro%e$re in%rease" so i the n$#'er of fail$res

an a!erse effe%ts" an the pro%e$re has 'een a'anone( The sa#e is tr$e for

the intra$ral in.e%tion of #eth&lprenisolone(

Other Ca$ses of S%iati%a an Low3Ba%- Pain

An in%reasin) e+perien%e with l$#'ar 'a%- pain" )l$teal ne$ral)ia" an s%iati%a has

i#presse the a$thors with the lar)e n$#'er of s$%h %ases that are $nsol!a'le( At

one ti#e all these %ases were %lassifie as s%iati% ne$ritis or >sa%roilia% strain(?

After Mi+ter an Barr pop$lari=e the %on%ept of prolapse is%" all s%iati%a an

l$#'ar pains were as%ri'e to this %onition( Operations 'e%a#e wiel& pra%ti%e"

not onl& for fran- is% protr$sion '$t also for >har is%s? /$nr$pt$re0 an relate

patholo)ies of the spine( The s$r)i%al res$lts 'e%a#e less an less satisfa%tor& $ntil

re%entl&" in lar)e referral %enters" as #an& patients were 'ein) seen with

$nrelie!e postla#ine%to#& pain as with $noperate r$pt$re is%s( To e+plain

these %hroni% pain %ases" a n$#'er of new patholo)i% entities" so#e of $n%ertain

stat$s" ha!e 'een es%ri'e( Entrap#ent of l$#'ar roots appears to 'e the

%onse,$en%e not onl& of is% r$pt$re '$t also of spon&loti% sp$rs with stenosis of

the lateral re%ess" h&pertroph& of apoph&seal fa%ets" %o#pression of the ner!e '&

the p&rifor#is #$s%le" an ara%hnoiitis( Lateral re%ess stenosis in parti%$lar #a&

'e a %a$se of s%iati%a not relie!e '& is% s$r)er&( Another s$rprisin) finin) in the

%o$rse of i#a)in) the spinal %anal is a %&st3li-e ilatation of the perine$rial sheath


21/29

/Tarlo! %&sts0( One or #ore sa%ral roots #a& 'e in!ol!e at points where the&

penetrate the $ra an 'e asso%iate with rai%$lar spto#s( There are reports of

relief fro# openin) the %&sts an freein) the roots( S%iati%a that is te#porall& lin-e

to the pre#enstr$al perio is not $n%o##on an is al#ost alwa&s $e to

eno#etriosis that in!ol!es the ner!e at the s%iati% not%h( We ha!e also o'ser!e

%ases of s%iati%a that o%%$rre with ea%h pre)nan%&(

These are '$t a few of the lar)e n$#'er of spinal a'nor#alities is%lose '& newer

raiolo)i% te%hni,$es( An atlas of these a'nor#alities@%on)enital an

e!elop#ental stenoses" Pa)et isease" apoph&seal .oint a'nor#alities in%l$in)

s&no!ial %&sts arisin) fro# the .oint" $nilateral spon&lolisthesis" tro%hanteri% an

is%hio)l$teal '$rsitis@are a#ira'l& presente in the sposi$# on CT of the

l$#'ar spine /see Referen%es" $ner >Sposi$#?0(

Co#pression of the %a$a e,$ina '& epi$ral t$#or" as es%ri'e f$rther on" #ost

often 'e)ins with 'a%- pain or s%iati%a" #ost often as a res$lt of eposits of

prostati% or 'reast %an%er or #&elo#a( The s%iati% ner!e or the ple+$s fro# whi%h itori)inates #a& 'e i#pli%ate in t$#or )rowths /lpho#a" ne$rofi'rosar%o#a0(

Se!eral infla##ator& iseases of the %a$a e,$ina pro$%e 'a%- pain an 'ilateral

s%iati%a an #a& 'e #ista-en for the #ore $s$al t&pes of %a$a e,$ina

%o#pression@%&to#e)alo!ir$s infe%tion in AIDS patients" Le isease" herpeti%

infe%tion" an neoplasti% #enin)itis at ti#es 'eha!e in this fashion( In all of these"

the CS1 shows an intense pleo%&tosis( The :$illain3Barr s&nro#e #a& also

pro$%e #isleain) 'a%- an rai%$lar pain 'efore wea-ness is apparent( The

%a$al roots in these iseases enhan%e with )aolini$# on MRI(

1inall& one #$st not o!erloo- the possi'le o%%$rren%e of a l$#'osa%ral ple+$s

ne$ritis" a $nilateral /o%%asionall& 'ilateral0 isorer a-in to 'ra%hial ne$ritis" ana%$te or s$'a%$te s%iati% or fe#oral ne$ropath& $e to ia'etes" herpes =oster" or a

retroperitoneal #ass" an& of whi%h #a& pro$%e a s&nro#e si#ilar to that of

r$pt$re is% /see Chap( 0(

L$#'ar Stenosis an Spon&loti% Ca$al Rai%$lopath& In the l$#'ar re)ion"

osteoarthriti% or spon&loti% %han)es #a& lea to %o#pression of one or #ore

%a$al roots( The pro'le# is e+a))erate if there is a %on)enitall& narrow l$#'ar

%anal( The roots are %a$)ht 'etween the posterior s$rfa%e of the !erte'ral 'o& an

the li)a#ent$# fla!$# posterolaterall&( Lateral re%ess stenosis" all$e to a'o!e"

#a& also %ontri'$te to root %o#pression(


22/29


23/29

witho$t si)ns of root %o#pression6 it is relie!e for a !aria'le perio '& in.e%tion of

the .oint with lio%aine or its eri!ati!es( Often one is $n%ertain whether it was the

anal)esi% effe%t on the .oint or the infiltration of the re)ion aro$n the ner!e root

that relie!e the pain( Two %ontrolle st$ies ha!e pro!ie e!ien%e of the

ineffi%a%& of another pop$lar treat#ent for this t&pe of low3'a%- pain" na#el&"

%orti%osteroi in.e%tions into the fa%et .oints /Carette et al6 Lili$s et al0(Notwithstanin) these st$ies" we ha!e fo$n the in.e%tion of anal)esi%s an

sterois in an aro$n the fa%et to 'e a $sef$l te#pori=in) #eas$re in so#e

patients( In an& %ase" this )ro$p of patients oes not re,$ire operation(

L$#'ar Ahesi!e Ara%hnoiitis This also is a so#ewhat !a)$e entit&" in whi%h the

ara%hnoi #e#'rane is thi%-ene an opa,$e in the !i%init& of the %a$a e,$ina(

The ter# is also applie to thi%-enin) of the ara%hnoial sheaths aro$n roots

/roots ha!e essentiall& no epine$ri$#0( It %an 'e seen in l$#'ar #&elo)ra#s in

whi%h the %ontrast #aterial fails to o$tline the roots an flow freel& in the

s$'ara%hnoi spa%e( A%%orin) to a British re!iew" l$#'ar ara%hnoiitis is rare"

ha!in) 'een seen in onl& 8 of 788 #&elo)ra#s( 9$)in) '& A#eri%an writin)s" itis #$%h #ore fre,$ent /see >Sposi$#"? in the Referen%es0( The $s$al %lini%al

feat$res are intra%ta'le low3'a%- an le) pain an paresthesias" all positional" in

%o#'ination with ne$rolo)i% a'nor#alities refera'le to l$#'ar spinal roots( In o$r

patients" #$ltiple #&elo)ra#s" is% r$pt$re" operati!e pro%e$res" infe%tions" an

s$'ara%hnoi 'leein) ha!e 'een %a$sall& in!ol!e( So#e %ases ha!e followe

spinal anesthesia an e!en epi$ral anesthesia '& a perio of #onths or &ears( The

pres$#ption is that the $ra ha 'een 'rea%he an often there were %lini%al si)ns

of an asepti% #enin)itis soon after the pro%e$re( The MRI #a& show e%%entri%all&

thi%-ene #enin)es in the spinal %anal with ara%hnoi ahesions an %olle%tions of

CS1 that ispla%e ner!e roots /1i)( 2230( Treat#ent is $nsatisfa%tor&( L&sis ofahesions an a#inistration of intrathe%al sterois ha!e 'een of no !al$e( Epi$ral

in.e%tion of sterois is o%%asionall& helpf$l" a%%orin) to so#e orthopeists(

1i)$re 223 Se!ere l$#'ar ara%hnoiitis %a$sin) 'a%- pain" s%iati%a" anparesthesias &ears after spinal anal)esia( L$#'ar MRI perfor#e with inf$sion of

)aolini$# showin) thi%-ene ara%hnoi an ispla%e#ent of %a$a e,$ine roots

'& a%,$ire ara%hnoi %&sts(


24/29

An-&losin) Spon&litis This isorer" referre to in the past as rhe$#atoi

spon&litis an as !on Be%hterew or Marie3Str$#pell arthritis" affe%ts &o$n) a$lt

#ales preo#inantl&( Its pre!alen%e in the )eneral pop$lation has 'een !ario$sl&

esti#ate at 2 to G per 2888( Appro+i#atel& F per%ent of patients with an-&losin)

spon&litis are #ar-e '& the histo%o#pati'ilit& anti)en HLA3B47 /whi%h is present

in onl& 7 per%ent of nonaffe%te persons0( Pain" $s$all& %entere in the low 'a%-" isthe #ain %o#plaint" at least in the initial sta)es of the isease( Often it raiates to

the 'a%- of the thi)hs an )roin( At first the spto#s are !a)$e /tire 'a%-"

>%at%hes? $p an own the 'a%-" sore 'a%-0" an the ia)nosis #a& 'e o!erloo-e

for #an& &ears( Altho$)h the pain is re%$rrent" li#itation of #o!e#ent is %onstant

an pro)ressi!e6 o!er ti#e" it o#inates the %lini%al pi%t$re( Earl& in the %o$rse" this

is e+perien%e as >#ornin) stiffness? or an in%rease in stiffness after perios of

ina%ti!it&6 these finin)s #a& 'e present lon) 'efore raiolo)i% %han)es are

#anifest( Rarel&" a %a$a e,$ina s&nro#e #a& %o#pli%ate an-&losin) spon&litis"

the res$lt apparentl& of an infla##ator& rea%tion an later a proliferation of

%onne%ti!e tiss$e in the %a$al %anal /Matthews0( Li#itation of %hest e+pansion"

tenerness o!er the stern$#" e%rease #otion an tenen%& to pro)ressi!e

fle+ion of the hips" an the %hara%teristi% i##o'ilit& an fle+ion efor#it& of the

spine />po-er spine?0 #a& 'e present earl& in the %o$rse of the isease( The

raiolo)i% hall#ar-s are" at first" estr$%tion an s$'se,$entl& o'literation of the

sa%roilia% .oints" followe '& 'on& 'ri)in) of the !erte'ral 'oies to pro$%e the

%hara%teristi% >'a#'oo spine(? When this o%%$rs" the pain $s$all& s$'sies" '$t the

patient has '& then little #otion of the 'a%- an ne%-( An-&losin) spon&litis #a&

also 'e a%%o#panie '& the Reiter s&nro#e" psoriasis" an infla##ator& iseases

of the intestine /see also Chap( 0( The )reat ris- in this isease is fra%t$re

islo%ation of the spine fro# relati!el& #inor tra$#a" parti%$larl& fle+ion3e+tension

in.$ries(

O%%asionall& an-&losin) spon&litis is %o#pli%ate '& estr$%ti!e !erte'ral lesions(

This %o#pli%ation sho$l 'e s$spe%te whene!er the pain ret$rns after a perio of

,$ies%en%e or 'e%o#es lo%ali=e( The %a$se of these lesions is not -nown" '$t the&

#a& represent a response to non$nion of fra%t$res" ta-in) the for# of an e+%essi!e

pro$%tion of fi'ro$s infla##ator& tiss$e( An-&losin) spon&litis" when se!ere" #a&

in!ol!e 'oth hips" )reatl& a%%ent$atin) the 'a%- efor#it& an isa'ilit&(

Rhe$#atoi arthritis" when it affe%ts the spine" #a& 'e %onfine to the %er!i%al

re)ion an is %onsiere f$rther on in this %hapter(

Neoplasti% an Infe%tio$s Diseases of the Spine Metastati% %ar%ino#a /'reast"

'ron%h$s" prostate" th&roi" -ine&" sto#a%h" $ter$s0" #$ltiple #&elo#a" an

lpho#a are the %o##on #ali)nant t$#ors that in!ol!e the spine( The pri#ar&

lesion #a& 'e s#all an aspto#ati% an the first #anifestation of the t$#or #a&

'e pain in the 'a%- $e to #etastati% eposits( The pain is es%ri'e as %onstant

an $ll6 it is often $nrelie!e '& rest an #a& 'e worse at ni)ht( Rai%$lar pain

#a& 'e ae" as es%ri'e earlier in the %hapter( At the ti#e of onset of the 'a%-


25/29

pain" there #a& 'e no raio)raphi% %han)es6 when s$%h %han)es o appear" the&

$s$all& ta-e the for# of estr$%ti!e lesions in one or se!eral !erte'ral 'oies with

little or no in!ol!e#ent of the is% spa%e" e!en in the fa%e of a %o#pression

fra%t$re( Before s$%h estr$%ti!e %han)es 'e%o#e e!ient" a CT or raioa%ti!e

isotope s%an #a& 'e helpf$l in ete%tin) areas of osteo'lasti% a%ti!it& $e to

neoplasti% or infla##ator& isease an %hara%teristi% %han)es are also e!ient onMRI(

Infe%tion of the !erte'ral %ol$#n" osteo#&elitis" is $s$all& %a$se '& staph&lo%o%%i

an less often '& %olifor# an t$'er%$le 'a%illi( The patient %o#plains of pain in the

'a%-" of s$'a%$te or %hroni% nat$re" whi%h is e+a%er'ate '& #o!e#ent '$t not

#ateriall& relie!e '& rest( Motion 'e%o#es li#ite" an there is per%$ssion3in$%e

tenerness o!er the spine in the in!ol!e se)#ents an pain with .arrin) of the

spine" as o%%$rs when the heels stri-e the floor( Often these patients are afe'rile

an o not ha!e a le$-o%&tosis( The er&thro%&te sei#entation rate is ele!ate as a

r$le( CT s%annin) an MRI will $s$all& e#onstrate the in!ol!e !erte'ra/e0 an

inter!erte'ral is%@the finin) of a 'rea%he is% spa%e is one of the feat$res thatifferentiates infe%tio$s fro# neoplasti% iseases of the spine( A para!erte'ral #ass

is often fo$n" ini%atin) an a's%ess" whi%h #a&" in the %ase of t$'er%$losis" rain

spontaneo$sl& at sites ,$ite re#ote fro# the !erte'ral %ol$#n( We ha!e also

en%o$ntere a n$#'er of patients with s$'a%$te 'a%terial eno%aritis who

%o#plaine of se!ere #iline thora%i% an l$#'ar 'a%- pain '$t ha no e!ient

infe%tion of the spine(

Spe%ial #ention sho$l 'e #ae of spinal epi$ral a's%ess" whi%h ne%essitates

$r)ent s$r)i%al treat#ent( Most often this is $e to staph&lo%o%%al infe%tion" whi%h

is %arrie in the 'loostrea# fro# a septi% fo%$s /e()(" f$r$n%le0 or is intro$%e into

the epi$ral spa%e fro# an osteo#&eliti% lesion( Another i#portant a!en$e of

infe%tion is the intra!eno$s self3a#inistration of a$lterate r$)s an $se of

%onta#inate neeles( Rarel& the infe%tion is intro$%e in the %o$rse of a l$#'ar

p$n%t$re" epi$ral in.e%tion" or la#ine%to#& for is% e+%ision( In so#e instan%es the

so$r%e of the epi$ral infe%tion %annot 'e as%ertaine( The #ain spto#s are

fe!er" le$-o%&tosis" an persistent an se!ere lo%ali=e pain" intensifie '&

per%$ssion an press$re o!er the !erte'ral spines6 aitionall& the pain #a&

a%,$ire a rai%$lar raiation( These spto#s #anate i##eiate in!esti)ation '&

MRI or CT3#&elo)raph& an s$r)i%al inter!ention" prefera'l& 'efore the si)ns of

paraple)ia" sphin%ter &sf$n%tion" an sensor& loss 'e%o#e #anifest( E+%eptionall&

s#all a's%esses %an 'e treate s$%%essf$ll& with anti'ioti%s alone( Anoninfla##ator& for# of a%$te epi$ral %o#pression #a& 'e $e to he#orrha)e

/anti%oa)$lant therap&" !as%$lar #alfor#ation0 an" in the %er!i%al re)ion" to

rhe$#atoi arthritis /see f$rther on0(

Intraspinal He#orrha)e S$en" e+%r$%iatin) #iline 'a%- pain /le %o$p e

poi)nar or >the stri-e of the a))er?0@often with rapil& e!ol!in) paraparesis"

$rinar& retention" an n$#'ness of the le)s@#a& anno$n%e the o%%$rren%e of


26/29

s$'ara%hnoi" s$'$ral" or epi$ral 'leein)( The %o##onest %a$se of s$%h an

e!ent is a spinal arterio!eno$s #alfor#ation /AM0" as is%$sse on pa)e 2G2(

Spinal arterial ane$r&s#s are #$%h less %o##on( It sho$l 'e #entione that 'a%-

pain of %o#para'le intensit& #a& #ar- the onset of a%$te #&elitis" spinal %or

infar%tion" %o#pression fra%t$re" an o%%asionall& :$illain3Barr s&nro#e(

Pain fro# is%eral Disease Pepti% $l%er isease an %ar%ino#a of the sto#a%h #ost

t&pi%all& in$%e pain in the epi)astri$#( Howe!er" if the posterior sto#a%h wall is

in!ol!e" parti%$larl& if there is retroperitoneal e+tension" the pain #a& 'e felt in

the thora%i% spine" %entrall& or to one sie" or in 'oth lo%ations( If intense" it #a&

see# to en%ir%le the 'o&( The 'a%- pain tens to refle%t the %hara%teristi%s of the

pain fro# the affe%te or)an6 e()(" if $e to pepti% $l%eration" it appears a'o$t 4 h

after a #eal an is relie!e '& foo an anta%is(

Diseases of the pan%reas are apt to %a$se pain in the 'a%-" 'ein) #ore to the ri)ht

of the spine if the hea of the pan%reas is in!ol!e an to the left if the 'o& an

tail are i#pli%ate( Retroperitoneal neoplas#s@e()(" lpho#as" h&pernephro#as"sar%o#as" an %ar%ino#as@#a& e!o-e pain in the thora%i% or l$#'ar spine with a

tenen%& to raiate to the lower part of the a'o#en" )roins" anterior thi)hs" or

flan-( A t$#or in the iliopsoas re)ion often pro$%es a $nilateral l$#'ar a%he with

raiation towar the )roin an la'ia or testi%le6 there #a& also 'e si)ns of

in!ol!e#ent of the $pper l$#'ar spinal roots( An ane$r&s# of the a'o#inal aorta

#a& in$%e pain that is lo%ali=e to an analo)o$s re)ion of the spine( The s$en

appearan%e of l$#'ar pain in a patient re%ei!in) anti%oa)$lants sho$l aro$se

s$spi%ion of retroperitoneal 'leein)( This pain #a& also 'e referre to the )roin(

Infla##ator& iseases an neoplas#s of the %olon %a$se pain that #a& 'e felt in

the lower a'o#en" the #il$#'ar re)ion" or 'oth( As with intense pain hi)her inthe spine" it #a& ha!e a 'elt3li-e istri'$tion( Pain fro# a lesion in the trans!erse

%olon or first part of the es%enin) %olon #a& 'e %entral or left3sie6 its le!el of

referen%e is to the se%on an thir l$#'ar !erte'rae( If the si)#oi %olon is

i#pli%ate" the pain is lower" in the $pper sa%ral spine an anteriorl& in the

s$prap$'i% re)ion or left lower ,$arant of the a'o#en( Retroperitoneal

appeni%itis #a& ha!e an o referral of pain to the low flan- an 'a%-(

:&ne%olo)i% isorers often #anifest the#sel!es '& 'a%- pain" '$t their ia)nosis

is selo# iffi%$lt( Thoro$)h a'o#inal palpation as well as !a)inal an re%tal

e+a#ination" s$pple#ente '& $ltraso$n an CT s%annin) or MRI" $s$all& is%loses

the so$r%e of pain( The $terosa%ral li)a#ents are the #ost i#portant pel!i% so$r%e

of %hroni% 'a%- pain( Eno#etriosis or %ar%ino#a of the $ter$s /'o& or %er!i+0 #a&

in!ae these str$%t$res" %a$sin) pain that is lo%ali=e to the sa%r$# either %entrall&

or #ore to one sie( In eno#etriosis" the pain 'e)ins pre#enstr$all& an often

#er)es with #enstr$al pain" whi%h also #a& 'e felt in the sa%ral re)ion( Rarel&"

%&%li% en)or)e#ent of e%topi% eno#etrial tiss$e #a& )i!e rise to s%iati%a an other

rai%$lar pain( Malposition of the $ter$s /retro!ersion" $ter$s es%ens$s" an


27/29

prolapse0 %hara%teristi%all& )i!es rise to sa%ral pain" espe%iall& after the patient has

'een stanin) for se!eral ho$rs( Chan)es in post$re #a& also e!o-e pain here

when a fi'ro#a of the $ter$s p$lls on the $terosa%ral li)a#ents( Low3'a%- pain with

raiation into one or 'oth thi)hs is a %o##on pheno#enon $rin) the last wee-s of

pre)nan%&(

Pain $e to %ar%ino#ato$s infiltration of pel!i% ner!e ple+$ses is %ontin$o$s an

'e%o#es pro)ressi!el& #ore se!ere6 it tens to 'e #ore intense at ni)ht an #a&

ha!e a '$rnin) ,$alit&( The pri#ar& lesion %an 'e in%onspi%$o$s an #a& 'e

o!erloo-e on pel!i% e+a#ination(

Co%%&&nia This is the na#e applie to pain that is lo%ali=e to the >tail pie%e"? the

three or fo$r s#all !esti)ial 'ones at the lower#ost part of the sa%r$#( The tra$#a

of %hil'irth" a fall on the '$tto%-s" a!as%$lar ne%rosis" a )lo#$s t$#or" or one of a

!ariet& of other rare t$#ors an anal isorers %an so#eti#es 'e esta'lishe as

the %a$se of pain in this re)ion( 1ar #ore often" the so$r%e re#ains o's%$re( In the

past" patients in this latter )ro$p were inis%ri#inatel& s$'.e%te to %o%%&)e%to#&"'$t #ore re%ent st$ies ha!e e#onstrate that #ost %ases respon fa!ora'l& to

in.e%tions of lo%al anestheti% an #eth&lprenisolone or to #anip$lation of the

%o%%&+ $ner anesthesia /Wra& et al0(

O's%$re T&pes of Low3Ba%- Pain an the $estion of Ps&%hiatri% Disease It is a safe

%lini%al r$le that all patients who %o#plain of low3'a%- pain ha!e so#e t&pe of

pri#ar& or se%onar& isease of the spine an its s$pportin) str$%t$res or of the

a'o#inal or pel!i% !is%era( Howe!er" e!en after %aref$l e+a#ination" there

re#ains a si=a'le )ro$p of patients in who# no patholo)i% 'asis %an 'e fo$n for

the 'a%- pain( Two %ate)ories %an 'e re%o)ni=e; one with post$ral 'a%- pain an

another with a))ra!atin) ps&%hiatri% illness" '$t there are alwa&s %ases where theia)nosis re#ains o's%$re(

Post$ral Ba%- Pain Man& slener" astheni% ini!i$als an so#e fat" #ile3a)e

ones ha!e %hroni% is%o#fort in the 'a%-" an the pain interferes with effe%ti!e

wor-( The ph&si%al e+a#ination is $nre!ealin) e+%ept for sla%- #$s%$lat$re an

poor post$re( The pain is iff$se in the #ile or lower re)ion of the 'a%-6

%hara%teristi%all&" it is relie!e '& 'e rest an in$%e '& the #aintenan%e of a

parti%$lar post$re o!er a perio of ti#e( Spinal #anip$lation is sai to ha!e helpe

a n$#'er of these patients( Pain in the ne%- an 'etween the sho$ler 'laes is a

%o##on %o#plaint a#on) thin" tense" a%ti!e wo#en an see#s to 'e relate to

ta$t trape=i$s #$s%les(

Aoles%ent )irls an 'o&s are s$'.e%t to an o's%$re for# of epiph&seal isease of

the spinal !erte'rae /S%he$er#ann isease0" whi%h" o!er a perio of 4 to G &ears"

#a& %a$se low3'a%- pain $pon e+er%ise(

Ps&%hiatri% Illness Low3'a%- pain #a& 'e a #a.or spto# in patients with h&steria"

#alin)erin)" an+iet& ne$rosis" epression" an h&po%honriasis as well as in #an&


28/29

ner!o$s persons whose spto#s o not %onfor# to an& of these ps&%hiatri%

illnesses( A)ain" it is )oo pra%ti%e to ass$#e that pain in the 'a%- in s$%h patients

#a& si)nif& isease of the spine or a.a%ent str$%t$res" an this sho$l alwa&s 'e

%aref$ll& so$)ht( Howe!er" e!en when so#e or)ani% fa%tors are fo$n" the pain #a&

'e e+a))erate" prolon)e" or wo!en into a pattern of in!aliis# 'e%a$se of

%oe+istent pri#ar& or se%onar& ps&%holo)i% fa%tors( This is espe%iall& tr$e whenthere is the possi'ilit& of se%onar& )ain /nota'l& wor-ers* %o#pensation or

settle#ent of personal in.$r& %lai#s0( Patients see-in) %o#pensation for protra%te

low3'a%- pain witho$t o'!io$s str$%t$ral isease ten" after a ti#e" to 'e%o#e

s$spi%io$s" $n%ooperati!e" an hostile towar their ph&si%ians or an&one who #i)ht

,$estion the a$thenti%it& of their illness( One notes in the# a tenen%& to es%ri'e

their pain !a)$el& an a preferen%e to is%$ss the e)ree of their isa'ilit& an

their #istreat#ent at the hans of the #ei%al profession( The es%ription of the

pain #a& !ar& %onsiera'l& fro# one e+a#ination to another( Often also" the

re)ion/s0 in whi%h pain is e+perien%e an its raiation are nonph&siolo)i%" an the

%onition fails to respon to rest an ina%ti!it&( These feat$res an a ne)ati!e

e+a#ination of the 'a%- sho$l lea one to s$spe%t a ps&%holo)i% fa%tor( A few

patients" $s$all& fran- #alin)erers" aopt the #ost 'i=arre )aits an attit$es" s$%h

as wal-in) with the tr$n- fle+e at al#ost a ri)ht an)le /%a#pto%or#ia0" an are

$na'le to strai)hten $p( Or the patient #a& 'e $na'le to 'en forwar e!en a few

e)rees" espite the a'sen%e of #$s%le spas#" an #a& win%e at the sli)htest

press$re" e!en o!er the sa%r$#" whi%h is selo# a site of tenerness $nless there is

pel!i% isease(

The epresse an an+io$s patient with 'a%- pain represents a tro$'leso#e

pro'le#( A %o##on error is to #ini#i=e the i#portan%e of an+iet& an epression

or to as%ri'e the# to worr& o!er the illness an its so%ial effe%ts( In these%ir%$#stan%es" %o##on an #inor 'a%- ail#ents" e()(" those $e to osteoarthritis

an post$ral a%he" et%(" are enhan%e an renere intolera'le( S$%h patients are

often s$'.e%te to $nne%essar& s$r)i%al pro%e$res( The isa'ilit& see#s e+%essi!e

for the e)ree of spinal #alf$n%tion" an #iser&" irrita'ilit&" an espair are the

pre!ailin) feat$res of the s&nro#e( One of the #ost relia'le ia)nosti% feat$res is

the response to r$)s or other #eas$res that alle!iate the epression /see Chap(

70(

1aile Ba%- S&nro#e

S$rel& the #ost iffi%$lt patients to #ana)e are those with %hroni% low3'a%- painwho ha!e alrea& ha one or #ore la#ine%to#ies an so#eti#es a f$sion witho$t

s$'stantial relief( In one lar)e series of patients operate on for pro!en is%

prolapse" 4 per%ent were left with tro$'leso#e spto#s an 28 per%ent re,$ire

f$rther s$r)er& /Weir an 9a%o's0( In s$%h patients o$r pra%ti%e has 'een to repeat

the MRI an CT3#&elo)raph&( In a s#all n$#'er of the patients" it will 'e fo$n that

the is% has rer$pt$re" or that there is a lateral re%ess stenosis" or that a is% has

r$pt$re at another le!el( It #a& happen that the s$r)eon i not re#o!e all the


29/29

is% tiss$e" in whi%h %ase another operation to re#o!e the re#ainer will 'e

s$%%essf$l( Ele%tro#&o)raph& an ner!e %on$%tion st$ies" sear%hin) for e!ien%e

of a rai%$lopath&" are helpf$l( If there is e!ien%e of a rai%$lopath& '$t no is%

#aterial" or onl& s%ar tiss$e is seen" one oes not -now whether the pain is $e to

in.$r& fro# the initial r$pt$re or was the after#ath of s$r)er&( ario$s e+planations

are then in!o-e@rai%$litis" lateral re%ess s&nro#e" fa%et s&nro#e" $nsta'lespine" an l$#'ar ara%hnoiitis es%ri'e earlier in the %hapter /see re!iews '&

$iles et al an '& Lon) as well as the >Sposi$#? liste in the Referen%es0(

One wo$l s$ppose that these %hroni% pain %ases %o$l 'e s$'i!ie into a )ro$p

with %ontin$e rai%$lar pain an another with referre pain fro# isease of the

spine( Howe!er" on%e the pain 'e%o#es %hroni%" the separation is not eas&(

Press$re o!er the spine" '$tto%-" or thi)h #a& %a$se pain to 'e pro.e%te into the

le)( Lio%aine 'lo%-s of ner!e roots ha!e &iele in%onsistent res$lts( O%%$pational

in.$ries" in whi%h wor-ers* %o#pensation or liti)ation is a fa%tor" #a-e the patient*s

report of therape$ti% effe%ts al#ost worthless( Trans%$taneo$s sti#$lators"

posterior %ol$#n sti#$lators" intrathe%al in.e%tions of anal)esi%s" an epi$ralsteroi in.e%tions ha!e selo# helpe for lon) in o$r e+perien%e( At present the

'est that %an 'e offere the patient is wei)ht re$%tion /if he is o'ese0" stret%hin)

an pro)ressi!e e+er%ise to stren)then a'o#inal an 'a%- #$s%les" as well as

nonsteroial anti3infla##ator& an antiepressant r$)s( A trial of #assa)e

therap& or a li#ite %o$rse of spinal #anip$lation is reasona'le(

Pre!enti!e Aspe%ts of Lower Ba%- Pain

Witho$t o$'t these are i#portant( There wo$l 'e #an& fewer 'a%- pro'le#s if

a$lts -ept their tr$n- #$s%les in opti#al %onition '& re)$lar slow stret%hin) an

e+er%ise s$%h as swi##in)" wal-in) 'ris-l&" r$nnin)" an %alistheni% pro)ra#s ofthe Canaian Air 1or%e t&pe( Mornin) is the ieal ti#e for e+er%isin)" sin%e the 'a%-

of the oler a$lt tens to 'e stiffest followin) a ni)ht of ina%ti!it&( This happens

re)arless of whether a 'e 'oar or stiff #attress is $se( Sleepin) with the 'a%-

h&pere+tene an sittin) for lon) perios in an o!erst$ffe %hair or a 'al&

esi)ne %ar seat are parti%$larl& li-el& to a))ra!ate 'a%-a%he( It is esti#ate that

intrais%al press$res are in%rease 488 per%ent '& %han)in) fro# a re%$#'ent to a

stanin) position an 88 per%ent when sl$#pe in an eas& %hair( Corre%t sittin)

post$re lessens this press$re( Lon) trips in a %ar or plane witho$t %han)e in position

p$t #a+i#al strain on is%al an li)a#ento$s str$%t$res in the spine( Liftin) fro# a

position in whi%h the 'a%- is fle+e" as in re#o!in) a hea!& s$it%ase fro# the tr$n-of a %ar" is ris-& /alwa&s lift with the o'.e%t %lose to the 'o&0( Also" s$en

stren$o$s a%ti!it& witho$t %onitionin) an war#$p is li-el& to in.$re is%s an their

li)a#ento$s en!elopes( Certain fa#ilies see# ispose to in.$r& of these str$%t$res(

pain in the lower back and limbs

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