8.25. Movements: flexion (7): Flexion in the thoracic spine may be measured with the upper point 30 cm from the previous zero mark. Thoracic flexion is not great, and is normally in the order of 3 cm. NB: to exclude the possibility of overlay, repeat these measurements with the patient distracted, sitting up, and leaning forward on the examination couch.
8.28. Movements: lateral flexion (2):
Alternatively, measure the angle formed between a line drawn through Tl, SI and the vertical. The average range is 30° to either side, and the contributions of the thoracic and lumbar spine are usually equal.
8.26. Movements: extension: Ask the patient to arch his back, assisting him by steadying the pelvis and pulling back on the shoulder. Pain is common in prolapsed intervertebral disc and in spondylolysis. Accurate assessment with a goniometer is difficult. The maximum theoretical range is thoracic 25°; lumbar 35°: normal total range about 30°. The decrease in distance between LI and SI on extension may also be measured with a tape.
8.29. Movements: rotation: The patient should be seated, and asked to twist round to each side. Rotation is measured between the plane of the shoulders and the pelvis. The normal maximum range is 40° and is almost entirely thoracic. (Lumbar contribution is 5° or less.) Some claim a more accurate assessment may be made if the test is carried out with the patient's arms folded across the chest.
8.27. Movements: lateral flexion (1):
Ask the patient to slide the hands down the side of each leg in turn, and record the point reached, either in centimetres from the floor, or the position that the fingers reach on the legs.
8.30. Suspected prolapsed intervertebral disc: Always start by screening the hips. Osteoarthritis of the hip and prolapsed intervertebral disc are frequently confused. A full range of rotation in the hips, performed at 90° flexion (I) without pain at the extremes, is generally sufficient to exclude osteoarthritis as a significant cause for the patient's complaints. Note that if there is complaint of pain on flexing the hip with the knee flexed (2) this negates a positive straight leg-raising test, and suggests osteoarthritis or overlay.
8.31. Suspected prolapsed intervertebral disc: Straight leg-raising test (1): If the hips are normal, raise the leg from the couch while watching the patient's face. Stop when the patient complains, and confirm that he is complaining of back or leg pain and not hamstring lightness (the test is negative if there is no pain). The production of paraesthesia or radiating root pains is highly significant, indicating nerve root irritation. Pain from S1 generally occurs before that from L5.
8.34. Straight leg raising (4): If there is some doubt regarding the severity or genuineness of the patient's complaints, ask him to sit up under the pretext of examining the back from behind. (Flexion of the spine may also be remeasured with the tape in this position.) The malingerer will have no difficulty, but the genuine patient will either flex the knees or fall back on the couch with pain (flip test).
8.32. Straight leg raising (2): Note the result (e.g. SLR (R) +ve at 60° or straight leg raising (R) full (no pain)). Note the site of pain: back pain suggests a central disc prolapse, leg pain a lateral protrusion. Distinguish and ignore hamstring tightness. Repeat on the good side. If well-leg raising produces pain and paraesthesia on the affected side, this is highly suggestive of a large prolapse close to the midline. Note that pain must be below the knee if the roots of the sciatic nerve are involved.
8.35. Straight leg raising (5y.Aird's test: Alternatively, ask the patient to sit with the legs over the edge of the examination couch. Now try to lift the leg until the knee is fully extended, and note the response. If extension is achieved, this is equivalent to a straight leg raising of 90°, and suggests that there is not a sound organic basis for any positive straight leg raising obtained when the patient is supine.
8.33. Straight leg raising (3): Now lower the leg until pain disappears (1 ■ then dorsiflex the foot (2). This increases tension on the nerve roots, generally aggravating any pain or paraesthesia ('+ve sciatic stretch test'). Try this, and record the response. Alternatively, once the level of pain has been reached, flex the knee slightly (3) and apply firm pressure with the thumb in the popliteal fossa over the stretched tibial nerve (4): radiating pain and paraesthesia suggest nerve root irritation (bow string test).
8.36. Suspected prolapses intervertebral disc: Functional overlay, continued: (2) Apply pressure to the head. Overlay is suggested if this aggravates the back pain. (3) Pinch the skin at the sides. Such superficial stimulation should not produce deep-seated back pain. (4) Any motor or sensory disturbance should be segmental and localized. Widespread weakness and/or stocking anaesthesia also suggest overlay (but do carry out a thorough neurological and circulatory examination).
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