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spinal pressure and may cause a shift in position of the root, has a similar effect In fact, any maneuver that stretches the nerve root eg, straight-leg raising in cases of sciatica evokes radicular pain The patterns of radicular pain due to involvement of particular roots are described in the sections on prolapsed discs further on in the chapter, and the distribution of cutaneous innervation of the spinal roots is shown in Figs 9-2 and 9-3 The most common pattern is sciatica, pain that originates in the buttock and is projected along the posterior or posterolateral thigh It results from irritation of the L5 or S1 nerve root Paresthesias or super cial sensory loss, soreness of the skin, and tenderness in certain circumscribed regions along the nerve usually accompany radicular pain If the anterior roots are involved as well, there may be re ex loss, weakness, atrophy, and fascicular twitching In patients with severe circumferential constriction of the cauda equina due to spondylosis (lumbar stenosis), sensorimotor impairment and sometimes referred pain are elicited by standing and walking The neurologic symptoms involve the calves and the backs of the thighs, thereby simulating the exercise-induced symptoms due to vascular insuf ciency hence the term spinal claudication (see page 179) Of importance is the observation that referred pain from structures of the lower back (sometimes called pseudoradicular) does not, as a rule, project below the knees and is not accompanied by neurologic changes other than a vague numbness without demonstrable sensory impairment The subcutaneous tissues within the area of referred pain may be tender Of course, local, referred, and radicular pain may occur together Pain resulting from muscular spasm usually occurs in relation to local pain The spasm may be thought of as a nocifensive re ex for the protection of the diseased parts against injurious motion Muscle spasm is associated with many disorders of the low back and can distort normal posture Chronic muscular contraction may give rise to a dull, sometimes cramping ache One can feel the tautness of the sacrospinalis and gluteal muscles and demonstrate by palpation that the pain is localized to them However, except for the most severe degrees of spasm in acute injury of the back, the contribution of this component to back pain is relatively small Other pains, often of undetermined origin, are sometimes described by patients with chronic disease of the lower part of the back: drawing and pulling in the legs; cramping sensation (without involuntary muscle spasm); tearing, throbbing, or jabbing pains; and feelings of burning or coldness These sensations, like paresthesias and numbness, should suggest the possibility of nerve or root disease In addition to assessing the character and location of the pain, one should determine the factors that aggravate and relieve it, its constancy, and its relationship to activity and rest, posture, forward bending, and cough, sneeze, and strain Frequently, the most important lead comes from knowledge of the mode of onset and the circumstances that initiated the pain Inasmuch as many painful conditions of the back are the result of injuries incurred during work or in automobile accidents, the possibility of exaggeration or prolongation of pain for purposes of compensation must always be kept in mind.

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The main goals of the examination of the back by the neurologist are to differentiate pain that is due to nerve root compression from

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musculoskeletal strains, metastatic spinal tumor, infectious and in ammatory diseases of the spine, and hip disease Some information may be gained by inspection of the back, buttocks, and lower limbs in various positions The normal spine shows a thoracic kyphosis and lumbar lordosis in the sagittal plane, which in some individuals may be exaggerated (swayback) In the coronal plane, the spine is normally straight or shows a slight curvature, particularly in women One should observe the spine closely for excessive curvature, a list, attening of the normal lumbar lordosis, presence of a gibbus (a sharp, kyphotic angulation usually indicative of a fracture), pelvic tilt or obliquity (Trendelenburg sign), and asymmetry of the paravertebral or gluteal musculature A sagging gluteal fold suggests involvement of the S1 root In sciatica one may observe a exed posture of the affected leg, presumably to reduce tension on the irritated nerve Or, patients in whom a free fragment of lumbar disc material has migrated posterolaterally may be unable to lie down and extend the spine The next step in the examination is observation of the spine, hips, and legs during certain motions It is well to remember that no advantage accrues from determining how much pain the patient can tolerate More important is to determine when and under what conditions the pain begins or worsens Observation of the patient s gait when he or she is unaware of being watched may disclose a subtle limp, a pelvic tilt, a shortening of step, or a stiffness of bearing indicative of a disinclination to bear weight on a painful leg One looks for limitation of motion while the patient is standing, sitting, and reclining When standing, the motion of forward bending normally produces attening and reversal of the lumbar lordotic curve and exaggeration of the thoracic curve With lesions of the lumbosacral region that involve the posterior ligaments, articular facets, or sacrospinalis muscles and with ruptured lumbar discs, protective re exes prevent exion, which stretches these structures As a consequence, the sacrospinalis muscles remain taut and prevent motion in the lumbar part of the spine Forward bending then occurs at the hips and at the thoracolumbar junction; also, the patient bends in such a way as to avoid tensing the hamstring muscles and putting undue leverage on the pelvis In the presence of degenerative disc disease, straightening up from a exed position is performed with dif culty and is aided to some extent by exing the knees Lateral bending is usually less instructive than forward bending, but in unilateral ligamentous or muscular strain, bending to the opposite side aggravates the pain by stretching the damaged tissues With unilateral sciatica, the patient lists to one side and strongly resists bending to the opposite side, and the preferred posture in standing is with the leg slightly exed at the hip and knee When the herniated disc lies lateral to the nerve root and displaces it medially, tension on the root is reduced and pain is relieved by bending the trunk to the side opposite the lesion; with herniation medial to the root, tension is reduced by inclining the trunk to the side of the lesion In the sitting position, exion of the spine can be performed more easily, even to the point of bringing the knees in contact with the chest The reason for this is that knee exion relaxes tightened hamstring muscles and relieves the stretch on the sciatic nerve Asking the seated patient to extend the leg so that the sole of the foot can be inspected is a way of checking for a feigned Lasegue ` sign (see below) Examination with the patient in the reclining position yields much the same information as in the standing and sitting positions With lumbosacral disc lesions and sciatica, passive lumbar exion.

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