8.37. Suspected prolapsed intervertebral disc: Functional overlay, continued: (5) Note the amount of rotation required to produce pain in the back. Now ask the patient to keep his hands firmly at his sides and repeat: the major part of the movement will now take place in the legs. Pain occurring with the same amount of apparent rotation again suggests overlay. In many centres, if three or more of the preceding tests are positive surgery is considered to be contraindicated.
8.38. Suspected prolapsed intervertebral disc: Reverse Lasegue test
(1) The patient should be prone. Flex each knee in turn. This gives rise to pain in the appropriate distributions (by stretching of femoral nerve roots) in high lumbar disc lesions.
8.39. Reverse Lasegue (2): The pain produced in such a test, if positive, is normally aggravated by extension of the hip, and this should be noted. Attempt this with the knee flexed to 90° (illustrated) and also fully flexed. High disc lesions are rare compared with those affecting the L5-S1 and L4-L5 spaces. Note also that pain in the ipsilateral buttock or thigh on full knee flexion may occur in more distally situated disc prolapses.
8.40. Suspected prolapsed intervertebral disc (2): Look for further evidence of neurological involvement. A reduced or absent tendon reflex is a highly significant finding accompanying positive straight leg raising or positive reverse Lasegue tests, but in practice confirmatory findings of this nature may not be present. Although two spinal segments are involved in both the knee and ankle reflexes, it is common practice to assess the integrity of L4 by the presence of the knee jerk (B), and that of si by the ankle jerk (A).
8.41. Suspected prolapsed intervertebral disc (3): Root pressure from a disc may affect myotomes and dermatomes in a rather selective fashion (see Segmental Innervation). Note the presence of any muscle wasting. Ask the patient to dorsiflex both feet. Now attempt to force them into plantarflexion against his resistance (L4, 5).
8.42. Suspected prolapsed intervertebral disc (3): Shift the grip to the great toes and test the power of dorsiflexion. Repeat with the lesser toes (L4. 5). Note that many regard weakness of dorsiflexion of the great toe as a most sensitive test of the L5 root alone, a root where there is no appropriate tendon reflex available for assessment. Now test the power of plantarflexion of the great and lesser toes (SI, 2).
8.43. Suspected prolapsed intervertebral disc (4): Encircle the feet with the hands and test the power of the peronei against the patient's resistance (L5, SI). Test the power of the quadriceps (L3, 4) when a high disc lesion is suspected. Note that prolonged muscle weakness will be accompanied by muscle wasting. Look for this clinically, and if you suspect it compare the girths of both the calves.
8.44. Suspected prolapsed intervertebral disc (5): Test sensation to pinprick in the dermatomes of the lower limb. Test perineal sensation in suspected central disc prolapse. Diminution of sensation at the side of the foot (SI) is one of the commonest findings (see also Segmental and Peripheral Nerves of the Limbs). Note also that stocking anaesthesia may be found in diabetic neuropathy and peripheral vascular disease, and is not necessarily evidence of a nonorganic problem.
8.45. Suspected thoracic cord compression: This may be crudely assessed by testing the abdominal reflexes. Use a blunt object such as the handle of a tendon hammer to stroke the skin in each paraumbilical skin quadrant. Failure of the umbilicus to twitch in the direction of the stimulated quadrant suggests cord compression on that side at the appropriate level. (The muscles of the upper quadrants are supplied by T7-10, and the lower by T10-L1.)
8.46. Suspected thoracic motor root dysfunction: Beevor's sign: The patient is asked to place his hands behind his head, flex his knees, and sit up. Movement of the umbilicus to one side (and up or down) suggests that the abdominal muscles on that side are unopposed, i.e. there is weakness on the opposite side. (See Frame 45 for the relevant muscle innervation.) This may result from nerve root compression by an osteophyte, from a local tumour, poliomyelitis or spinal dysraphism.
8.47. Suspected ankylosing spondylitis: Check the patient's chest expansion at the level of the fourth interspace. The normal range in an adult of average build is at least 6 cm. Less than 2.5 cm is regarded as highly suggestive of ankylosing spondylitis. In addition, look for evidence of iritis, which is often associated with this condition.
8.48. Suspected sacroiliac joint involvement (1): Flex the hip and knee and forcibly adduct the hip. Pain may accompany this manoeuvre in early ankylosing spondylitis, tuberculosis and other infections, and Reiter's syndrome, but many false positives do occur with this test.
8.49. Suspected sacroiliac joint involvement (2): Note whether pain is produced by pelvic compression or by trying to 'open out' the pelvis with the thumbs hooked round the anterior spines. Alternatively, with the patient in the prone position, place the side of one hand over the sacrum and upper natal cleft: press down hard, using the other hand to assist. True sacroiliac pain may occur in women shortly before and after childbirth.
8.50. Abdominal examination: This is an essential part of the investigation of all cases of back pain. Rectal or vaginal examination may be required on the indication of the history and any other elements in the case. The sacrococcygeal joint may be examined by first grasping the coccyx between the index (in the rectum) and the thumb outside, and then gently moving the joint. In coccydynia, marked pain normally accompanies this manoeuvre.
8.51. Circulation: The peripheral pulses and circulation should also be checked in all cases. Back and leg pain caused by arterial insufficiency is usually aggravated by activity, and absence of femoral pulsation is of particular significance.
8.53. Radiographs (l):An anteroposterior and lateral are the standard projections for both the lumbar and thoracic spine. Localized views of the lumbosacral junction are a useful addition. This is a typical example of a normal lateral radiograph of the lumbar spine. In filling out the request card, if a specific-area is under suspicion state this if possible, so that the central ray of the projection can be appropriately positioned.
8.54. Radiographs (2): Normal lateral thoracic spine.
8.52. Sedimentation rate: Estimation of the sedimentation rate is a valuable screening test in the investigation of all spinal complaints. It is normal in prolapsed intervertebral disc, mechanical back pain, spinal stenosis and Scheuermann's disease, but elevated in ankylosing spondylitis, many infections and neoplasms. It is best if 25 mm is taken as the upper limit of normal. False positives are not uncommon, but false negatives are rare.
8.55. Radiographs (3): In the lateral, note first the lumbar curve: (A) typical normal; (B) loss of lordosis (most often seen in prolapsed intervertebral disc as a result of protective muscle spasm, but not confirmatory).
8.56. Radiographs (4): In the thoracic spine note (Ala typical normal curve; (B) an increased but regular curve typical of senile kyphosis. Scheuermann's disease is another frequent cause of a regular dorsal kyphosis. Kyphosis may be measured on the radiographs with the technique for assessing scoliosis (see later). 45° is taken as the upper limit of normal.
8.57. Radiographs (5): In both the lumbar and the thoracic spine note any sharp alteration in the curvature (angular kyphosis), found typically where there is pathology restricted to one or two vertebral bodies, e.g. from fractures. TB or other infections, tumour, osteoporosis and osteomalacia with local vertebral body collapse.
8.58. Radiographs (6): Now look at the shape of the bodies and the size of the discs. Compare with the bodies and disc spaces above and below. The following are normal in the child's spine: (A) anterior clefts, (B) anterior notches, (C) incomplete fusion of elements, (D) epiphyses, (E) vascular tracks (which may persist).
8.59. Radiographs (7): Note (A) disc calcification; (B) the typical appearance of Scheuermann's disease, with (C) kyphosis,
(D) anterior wedging of not less than 5° involving at least three sequential vertebrae,
(E) ragged appearance of the epiphyses. Note
(F) a central disc herniation (Schmorl's node); this is not always associated with Scheuermann's disease.
8.60. Radiographs (8): Note (A): disc narrowing at any level in the spine is the earliest evidence of tuberculosis and other infections: (B) Narrowing at L5-S1 and, less commonly, in the two spaces above occurs in long-standing disc lesions and is often associated with anterior lipping.
8.61. Radiographs (9); Note (A) increased density and the 'picture-frame' appearance of the vertebra] bodies in Paget's disease; (Bl marked narrowing and increased density seen in Calve's disease (vertebra plana); (C) any space-occupying lesion in a vertebral body (usually due to tumour or infection (but note Schmorl's nodes)); (D) corner vertebra] erosions (Romanus lesions), seen in ankylosing spondylitis.
8.62. Radiographs (10): Note the relationship of each vertebra to its neighbour. In particular, note (A) spondylolisthesis (see also later); (B) retro.spondylolisthesis (usually associated with disc degeneration).
8.63. Radiographs (11): Lipping is seen in chronic disc lesions, mainly at L5-S1. but also at the other rarer disc prolapse sites. Note (A) anterior lipping; (B) posterior lipping. Lipping is also the main feature (at all levels) of osteoarthritis. Note (C) impingement of spinous processes ('kissing spines').
8.64. Radiographs (12): Normal anteroposterior view of the lumbar spine.
8.65. Radiographs (13): Normal anteroposterior view of the thoracic spine.
8.66. Radiographs (14): In the anteroposterior view note the presence of any congenital abnormalities, such as (A) congenita] vertebral fusion, often associated with a congenita] scoliosis; (B) anterior spina bifida, in which there is failure of fusion of the vertebral body elements (this is usually symptom free).
8.67. Radiographs (15): Note also any anomalies of the lumbosacral articulation, such as (C) partial sacralization of the fifth lumbar vertebra, a possible cause of low back pain. Note also (D) the presence of (posterior) spina bifida.
8.68. Radiographs (16): Note (A) the presence of any localized lateral angulation of the spine due to lateral vertebral collapse, e.g. from fracture, infection, tumour, osteoporosis or other causes: (B) hemivertebra, a common cause of congenital scoliosis (note that, as illustrated, this is usually associated with an extra rib).
8.69. Radiographs (17): Look at the soft tissue shadows at the sides of the vertebrae, observing, for example, the fusiform increased density typical of a tuberculous abscess. Note disc obliteration and early lateral wedging.
8.70. Radiographs (18): Examine the psoas shadows for symmetry. Lateral displacement of the edge of the shadow, and increased density within the main area occupied by psoas, suggests a psoas abscess, typically found in tuberculosis of the lumbar or lowermost thoracic spine.
8.71. Radiographs (19): Look for lateral lipping. (A); at D12-LI it may be an early sign of ankylosing spondylitis, but there and elsewhere it usually indicates osteoarthritis. 'Bamboo spine' (B) is diagnostic of ankylosing spondylitis. Note any body and facet joint fusions and ligament calcification.
8.72. Radiographs (20): Look at the sacroiliac joints. (A) Unilateral involvement (sclerosis, cystic changes or obliteration) may occur in tuberculosis and other infections. Any asymmetry should be investigated by oblique projections and. if necessary, tomography or CT scans. Bilateral involvement (B) is common in ankylosing spondylitis, and should always be sought when this condition is suspected.
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