Examination of Patient with Low Back Pain

As a result of abnormal movement at the facet joint, a hypertrophic, osteoarthritic process known as spondylosis develops. Enlargement of the facet joints by this spondylotic process narrows the intervertebral foramen, which may cause mechanical pressure on the exiting nerve root. In some persons, the anteroposterior diameter of the spinal canal is narrow, with deep lateral recesses. Thus the spondylotic process produces spinal stenosis, which causes pressure on the dural sac and cauda equina.

CLINICAL MANIFESTATIONS

Lumbar spine disease may be manifested by pain in the low back, a monoradicular syndrome, a cauda equina syndrome, or spinal stenosis. As an isolated symptom, low back pain is usually self-limited and responds to conservative measures.

Initially, only a detailed history and physical examination may be necessary (see Plate 4-3). However, increasing pain with or without neurologic symptoms in a person who has systemic symptoms raises the question of a destructive lesion and merits further investigation, especially if the response to treatment has been limited. Back pain that is not helped by lying down is non-specific but occurs with cancer or infections.

The monoradicular syndromes are the classic syndromes of a ruptured disk. Most disk ruptures occur at L5-S1 and L4-5. The herniated disk at L5-S1 usually compresses the S1 root as it passes the interspace on its way beneath the S1 facet. In the same manner, the L4-5 disk compresses the L5 root, and the L3-4 disk compresses the L4 root. Rarely, the disk extrudes laterally into the intervertebral foramen, and then the L5-S1 disk produces an L5 root syndrome; the L4-5 disk, an L4 root syndrome; and the L3-4 disk, an L3 root syndrome. Failure to diagnose these problems accurately results in inadequate treatment.

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