Examination of the Back

Much information can be obtained from simple inspection of the back, buttocks, and lower extremities as the patient assumes various positions. When the patient is standing, the presence of an excessive curvature (of the normal dorsal kyphosis or lumbar lordosis), a gibbus (from vertebral fracture), a step deformity (from lumbar spondylolisthesis), a pelvic tilt (from a lateral prolapsed disc), and a sagging gluteal fold (from an S1 root lesion) are all helpful diagnostic signs.

The patient is then observed walking, sitting, and lying down. All the natural motions may be impeded. Forward bending with knees extended may be limited by pain and spasm, the lumbar spine may be straight and immobile, and tautness of the sacrospinalis muscles may be visible. With degenerative spine disease, straightening up from a flexed position is characteristically slow, stiff, and variably uncomfortable. In unilateral sciatica, there is often a list to the painful side (sometimes to the opposite side), and the affected leg may be held slightly flexed at the hip and knee. However, hyperextension of the lumbar spine is usually not restricted or painful, either with the usual types (L4—5, L5-S1) of prolapsed disc or with lumbosacral strain. It is restricted with vertebral fracture or inflammatory disease of the articular facets or other structures. One also looks for muscle atrophy on the side of the pain.

Of the tests performed by the examiner, straight-leg raising is the most useful. In cases of prolapsed disc, with the patient supine, lifting the leg with the knee fully extended is limited by pain and hamstring muscle spasm (Lasegue sign). Straight-leg raising on the opposite side may also be limited and may evoke pain in the affected limb. Abduction and rotation of the hip are painful in diseases of the hip joint.

A search for tender areas is the last step. The finding of such areas, as indicated in Fig. 11-1, is suggestive of disease in the designated structures.

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