Low back pain is defined as pain with or without leg pain,
muscle tension and stiffness. It is localized in the area between the lower gluteal fold and rib border
. Studies show that its lifetime frequency is 84%
. Any pathological change in the lumbar spine structure can be a source of pain.
These sources of pain may be disc, nerve root, intradural structures, ligaments, facet joints,
sacroiliac joints and muscles around the spine. The intervertebral disc
itself is one of the common causes of low back pain, and pain due to disc herniation was described 75 years ago
and pain due to internal disc damage was described 90 years ago. In later studies, the intervertebral disc itself was shown as the source of pain, using various terms such as discogenic pain, internal disc damage, painful degenerative disc disease. Disc herniation is used to describe disc material that extends beyond the intervertebral disc space. There may be pressure on the nerve root due to disc herniation, and in this case the term lumbasacral radiculopathy is used. Internal disk
damage is defined as a situation in which the internal structure of the disk is damaged but its outer surface is normal
. The term lumbar discopathy covers all three definitions.
Disc herniations are most commonly seen at the L4-5, L5-S1 levels. L5 and S1 nerve roots are the most frequently affected
Disc herniation can affect the nerve roots in the cauda equina
and cauda
which is characterized by bladder, bowel and sexual dysfunction and perianal anesthesia, may cause equina syndrome.
A good anamnesis and detailed physical examination are required to diagnose lumbar discopathy
Inspection should be done. If there is a serious underlying spinal pathology after anamnesis and physical examination, imaging of the lumbar spine is required
.
WHAT IS THE PATIENT'S HISTORY IN LUMBAR DISCOPATHY?
History helps distinguish low back pain due to lumbar discopathy from other causes of low back pain
. In the study conducted by Vucetic et al. in low back pain
al The diagnostic accuracy of the history taken in terms of lumbar disc herniation has been found to be high
.
Pain due to lumbar discopathy is classically described as girdle-like
and is accompanied by lumbar flexion (leaning forward). is getting worse. However, this is not always
valid. The pain may be one-way, radiating towards the hip or leg.
It may increase with pressure changes in the cerebrospinal fluid such as coughing, sneezing and straining
. More than half of the patients report that there is no reason that could cause the pain to start. Approximately 20% report a history of heavy lifting and 10% report a rotational trunk movement. The remaining reasons in smaller proportions
are; trauma, sporting activity, bending forward, cold, poor sitting position.
The type and spread of pain varies depending on the condition of the disc problem. It may start locally in the waist
and after a while spread to the hip or sacroiliac region.
Pain may also spread to the thigh and foot. In some patients, it may start with a direct sciatalgia-like pain without any low back pain.
In a study conducted by Vroomen et al., 'pain distribution', lumbar disc
It is stated as the only useful history in making the diagnosis of sciatica due to disease.
It is important to identify 'red flags' and potential 'yellow flags' during the history.
Anamnetic findings that suggest a serious underlying cause such as malignancy, infection, or compression fracture are defined as 'red flag'. In the presence of these
findings, further examinations are required. The specificity of the red flag symptoms taken in the history in terms of the serious underlying causes of low back pain has been found to be high.
Red flags: Special attention and sometimes quick attention in the history and examination. /p>
pathological symptoms and signs requiring action
- children under 20 years of age with severe low back pain or onset later than age 55
- history of severe trauma
- constant, progressive night pain
- back pain
- history of cancer
- systemic steroids
- drug abuse, HIV infection
- unexplained weight loss
- fever
- systemic disease
p>- common neurological symptoms (including cauda equine syndrome)
- persistent severe limitation of movement
- severe pain with slight movement
- structural deformity
- difficulty urinating
- loss of anal sphincter tone or fecal incontinence, saddle-style anesthesia
- generalized progressive motor weakness or gait disturbance
In addition to describing specific factors about the pain, one purpose of taking a history
is to learn the patient's perspective and experience of the disease. Psychosocial factors are valuable in determining prognosis
and these are collected under the title of 'yellow flags'
. Yellow flags are the determining factors in the chronicity of pain and the development of long-term disability. The clinician should be more careful in their presence
.
Yellow flags
- job dissatisfaction
- catastrophic thought pattern for pain
- presence of depression,
- long-term rest
HOW SHOULD THE PHYSICAL EXAMINATION BE IN LUMBAR DYSCOPATHY?
The basic steps of physical examination are inspection (visual examination),
palpation (examination by touch), joint range of motion and neurological examination.
Some special tests that lead to lumbar discopathy are also important in diagnosis.
The entire posture is inspected to detect muscle imbalance and structural abnormalities. Physiological curvatures of the spine, hip, knee and foot positions in the sagittal plane are observed. A decrease in lumbar lordosis suggests paravertebral muscle spasm that may develop secondary to lumbar discopathy, and an increase suggests abdominal muscle weakness. The level of the shoulders, vertebral column, pelvis
position and extremities are evaluated from the front-back view. Sideways bending may be due to structural scoliosis
as well as functional scoliosis due to lumbar discopathy.
The gait pattern is examined for neurological and joint problems. Pathological walking patterns such as antalgic pain,
short leg gait, foot drop It is evaluated.
Palpation
While the patient is standing, both crista iliac and spina iliac posterior superior
palpation is performed and evaluated in terms of height difference. One of the reasons for the height difference
is functional scoliosis, which may develop due to lumbar discopathy.
Palpation of the paraspinal muscles on the lateral sides of the spinous processes is important in terms of tone
evaluation. Afterwards, the patient is laid face down, the superficial muscles are relaxed, and the deep paraspinal muscles, such as the multifidus muscle, are palpated. Tender points and muscle spasms are checked. Segmental blockage that may be caused by lumbar discopathy can be evaluated with the skin rubbing test, which is an examination method that uses palpation
. In this test, a sliding movement is made on the paraspinal muscles from bottom to top with the pulp of the index and middle fingers
. The test is considered positive if any resistance is encountered during this shifting movement.
Joint Range of Motion Evaluation
While the patient is standing, forward flexion, extension, lateral flexion and trunk
Rotations are checked.
Pain may occur in the lower back during spinal movements in different planes
and this gives us an idea about the localization of lumbar disc herniation. Generally,
posterolateral discs are painful in flexion, lateral discs are painful during ipsilateral bending, and central
discs are painful in extension.
During the range of motion evaluation of the lumbar spine, the presence of the centralization
phenomenon is investigated. The centralization phenomenon was described by McKenzie
in 1981. It is defined as pain becoming more proximal than distal during lumbar flexion and extension (patient bending forward and backward). The positivity of this
phenomenon increases the possibility that low back pain is due to lumbar disc disease
.
Special Tests
Straight leg stretching test: The patient is on his back. While lying down, the leg is lifted by holding the foot, with the knee in extension.
The angle and pain distribution should be noted when the pain begins.
If there is pain radiating from the waist to the leg, the test is considered positive. is done. In the studies conducted, the sensitivity of the straight leg lift test in diagnosing root compression due to lumbar disc disease was found to be 73-98%. However
its specificity is low. It indicates root compression at the L5,S1 level.
Lasegue test: It is helpful in distinguishing between hamstring muscle shortness and L5-S1 root irritation
. If the patient has hamstring shortness, there will be a limitation during the straight leg stretching test and there will be a stretching at the back of the leg. At the point where the pain begins and the tension occurs, the leg is lowered by 10 cm and the foot is brought into dorsiflexion. Reoccurrence of pain radiating to the leg
confirms root irritation.
Femoral nerve stretch test: While the patient is lying face down, the hip is brought to hyperextension with the knee in extension
. Pain in the waist and front of the thigh
It indicates L3, L4 root compression secondary to lumbar discopathy.
Cross straight leg stretch test: Lifting the straight leg to the leg without pain
test is performed and radicular pain is present in the painful leg. Its specificity has been found to be high
(4,8,14). It is positive in wide-based disc herniations.
Bowstring test: During the straight leg raising test, at the point where pain occurs, the knee is flexed 20 degrees and pressure is placed on the popliteal area with both hands
applied. If the pain occurs again, the test is positive
Valsalva maneuver: If the patient has radicular pain with straining, it means that the test is positive
Milgram test: The patient will lie on his back with his knees in extension. In this way
he lifts his legs off the ground by 5 cm. Failure to maintain this position for 30 seconds and feeling pain in the waist
suggests extrathecal or intrathecal spinal pathology.
Naffziger test: The examiner stands behind the patient
while the patient is standing or sitting. passes and applies pressure to the jugular vein with his fingers and asks the patient to cough
. In this way, intraspinal fluid pressure increases. Pain in the waist or leg
indicates nerve root irritation.
Brudzinski-kernig test: The patient lies on his back with his hands behind his head
he tries to touch his chin to his chest. Pain
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