PAIN IN THE LOWER BACK AND LIMBS The lower parts of the spine an pel!is" with their #assi!

e #$s%$lar atta%h#ents" are relati!el& ina%%essi'le to palpation an inspe%tion( Altho$)h so#e ph&si%al si)ns an ra io)raphs are helpf$l" ia)nosis often epen s on the patient*s es%ription of the pain an his or her 'eha!ior $rin) the e+e%$tion of %ertain #ane$!ers( Seasone %lini%ians" for these reasons" ha!e %o#e to appre%iate the nee for a s&ste#ati% in,$ir& an #etho of e+a#ination" the es%riptions of whi%h are pre%e e here '& a 'rief %onsi eration of the anato#& an ph&siolo)& of the spine( Anato#& an Ph&siolo)& of the Lower Part of the Ba%The 'on& spine is a %o#ple+ str$%t$re" ro$)hl& i!isi'le into an anterior an a posterior part( The for#er %onsists of a series of %&lin ri% !erte'ral 'o ies" arti%$late '& the inter!erte'ral is%s an hel to)ether '& the anterior an posterior lon)it$ inal li)a#ents( The posterior ele#ents are #ore eli%ate an e+ten fro# the 'o ies as pe i%les an la#inae that for#" with the posterior aspe%ts of the 'o ies an li)a#ents" the !erte'ral %anal( Sto$t trans!erse an spino$s pro%esses pro.e%t laterall& an posteriorl&" respe%ti!el&" an ser!e as the ori)ins an insertions of the #$s%les that s$pport an prote%t the spinal %ol$#n( The 'on& pro%esses are also hel to)ether '& st$r & li)a#ents" the #ost i#portant 'ein) the li)a#ent$# fla!$#( The posterior parts of the !erte'rae arti%$late with one another at the iarthro al apoph&seal /fa%et0 .oints" ea%h of whi%h is %o#pose of the inferior fa%et of the !erte'ra a'o!e an the s$perior fa%et of the one 'elow( These anato#i% feat$res are ill$strate in 1i)( 2232 an 1i)( 2234( The fa%et an sa%roilia% .oints" %o!ere '& s&no!ia" the %o#pressi'le inter!erte'ral is%s" an the %olla)eno$s an elasti% li)a#ents per#it a li#ite e)ree of fle+ion" e+tension" rotation" an lateral #otion of the spine(

1i)$re 2232 The fifth l$#'ar !erte'ra !iewe fro# a'o!e /A0 an fro# the si e /B0

1i)$re 2234 The #ain li)a#ento$s str$%t$res of the spine( A( B$%-lin) of the &ellow li)a#ent /li)a#ent$# fla!$#0 #a& %o#press the ner!e root or the spinal ner!e at its ori)in in the inter!erte'ral fora#en" parti%$larl& if the fora#en is narrowe '& osteoph&ti% o!er)rowth( B( Posterior aspe%t of the !erte'ral 'o ies( 1i'ers of the posterior lon)it$ inal li)a#ent #er)e with the postero#e ial portion of the ann$l$s fi'ros$s" lea!in) the posterolateral portion of the ann$l$s relati!el& $ns$pporte ( /Reprinte '& per#ission fro# 1inneson(0

The sta'ilit& of the spine epen s on the inte)rit& of the !erte'ral 'o ies an inter!erte'ral is%s an on two t&pes of s$pportin) str$%t$res" li)a#ento$s /passi!e0 an #$s%$lar /a%ti!e0( Altho$)h the li)a#ento$s str$%t$res are ,$ite stron)" neither the& nor the !erte'ral 'o &5 is% %o#ple+es ha!e s$ffi%ient inte)ral stren)th to resist the enor#o$s for%es that #a& a%t on the spinal %ol$#n6 the sta'ilit& of the lower 'a%- is therefore lar)el& epen ent on the !ol$ntar& an refle+ a%ti!it& of the sa%rospinalis" a' o#inal" )l$te$s #a+i#$s" an ha#strin) #$s%les( The !erte'ral an para!erte'ral str$%t$res eri!e their inner!ation fro# the #enin)eal 'ran%hes of the spinal ner!es /also -nown as re%$rrent #enin)eal or sin$!erte'ral ner!es0( These #enin)eal 'ran%hes sprin) fro# the posterior i!isions of the spinal ner!es .$st istal to the orsal root )an)lia" re3enter the spinal %anal thro$)h the inter!erte'ral fora#ina" an s$ppl& pain fi'ers to the intraspinal li)a#ents" perioste$# of 'one" o$ter la&ers of the ann$l$s fi'ros$s /that en%lose the is%0" an %aps$le of the arti%$lar fa%ets( Coppes an asso%iates ha!e fo$n A3 an C pain fi'ers e+ten in) into the inner la&ers of the ann$l$s an e!en the n$%le$s p$lpos$s( Altho$)h the spinal %or itself is insensiti!e" #an& of the %on itions that affe%t it pro $%e pain '& in!ol!in) these a .a%ent str$%t$res( The sensor& fi'ers fro# these str$%t$res an the l$#'osa%ral an sa%roilia% .oints enter the spinal %or !ia the fifth l$#'ar an first sa%ral roots( Motor fi'ers e+it thro$)h the %orrespon in) anterior roots an for# the efferent li#' of se)#ental refle+es( The s&#patheti% ner!es %ontri'$te onl& to the inner!ation of 'loo !essels( The spinal roots in the l$#'ar re)ion" after e+itin) fro# the spinal %or " %o$rse ownwar in the spinal %anal an are )ra $all& ispla%e laterall& $ntil the& an)$late an e+it at the inter!erte'ral fora#ina( Prior to enterin) the short fora#inal %anal" the spinal root lies in a shallow f$rrow alon) the inner s$rfa%e of the pe i%le ter#e the lateral re%ess( This is a %o##on site of root entrap#ent '& is% fra)#ents an 'on& o!er)rowth( The parts of the 'a%- that possess the )reatest free o# of #o!e#ent an hen%e are #ost fre,$entl& s$'.e%t to in.$r& are the l$#'ar" l$#'osa%ral" an %er!i%al( In

a ition to 'en in)" twistin)" an other !ol$ntar& #o!e#ents" #an& a%tions of the spine are refle+i!e in nat$re an are the 'asis of post$re( A)in) Chan)es in Spinal Str$%t$res Chan)es in the inter!erte'ral is%s an li)a#ents as a %onse,$en%e of a)in) an perhaps a s$%%ession of #inor tra$#as 'e)in to o%%$r as earl& as the first part of the thir e%a e( Deposition of %olla)en an elastin an alterations of )l&%osa#ino)l&%ans %o#'ine to e%rease the water %ontent of the n$%le$s p$lpos$s6 %on%o#itantl&" the %artila)eno$s en plate 'e%o#es less !as%$lar /Hassler0( The eh& rate is% thins o$t an 'e%o#es #ore fra)ile( Si#ilar %han)es o%%$r in the ann$l$s of the is%" whi%h fra&s to an in%reasin) e)ree with the passa)e of ti#e" per#ittin) the n$%le$s p$lpos$s to '$l)e an " so#eti#es with in.$r&" to e+tr$ e( This pro%ess %an 'e o'ser!e '& #a)neti% resonan%e i#a)in) /MRI0" whi%h shows a )ra $al re $%tion in the hi)h si)nal of the n$%le$s p$lpos$s with the passa)e of ti#e( In wo#en who ha MRI for )&ne%olo)i% reasons" Powell an %owor-ers fo$n an in%reasin) fre,$en%& of l$#'ar is% e)eneration an '$l)in)" approa%hin) 78 per%ent '& the fiftieth &ear of life( Si#ilar a'nor#alities in as&#pto#ati% #en an wo#en ha!e 'een re%or e '& 9ensen an %ollea)$es( The shrin-a)e of the is% alters the ali)n#ent of the arti%$lar fa%ets an !erte'ral 'o ies" lea in) so#eti#es to fa%et arthropath& an sp$r for#ation( The latter %han)es #a& %ontri'$te to stenosis of the spinal %anal an %o#pro#ise the lateral re%esses of the %anal an the inter!erte'ral fora#ina" where the& #a& i#pin)e on ner!e roots( Osteoporosis" espe%iall& in ol er wo#en" is an i#portant %a$se of !erte'ral flattenin) or %ollapse" a itionall& narrowin) the spinal %anal( :eneral Clini%al 1eat$res of Low3Ba%- Pain T&pes of Low3Ba%- Pain Of the se!eral s&#pto#s of spinal isease /pain" stiffness" li#itation of #o!e#ent" an efor#it&0" pain is of fore#ost i#portan%e( 1o$r t&pes of pain #a& 'e istin)$ishe ; lo%al" referre " ra i%$lar" an that arisin) fro# se%on ar& /prote%ti!e0 #$s%$lar spas#( These se!eral t&pes of pain %an often 'e is%erne fro# the patient*s es%ription6 relian%e is pla%e #ainl& on the %hara%ter of the pain" its lo%ation" an %on itions that #o if& it( Lo%al pain is %a$se '& an& patholo)i% pro%ess that i#pin)es $pon str$%t$res %ontainin) sensor& en in)s( In!ol!e#ent of the perioste$#" %aps$le of apoph&seal .oints" #$s%les" ann$l$s fi'ros$s" an li)a#ents is often e+,$isitel& painf$l" whereas estr$%tion of the !erte'ral 'o & or n$%le$s p$lpos$s alone pro $%es little or no pain( Lo%al pain is #ost often es%ri'e as stea & an a%hin)" '$t it #a& 'e inter#ittent an sharp an " tho$)h not well %ir%$#s%ri'e " is alwa&s felt in or near the affe%te part of the spine( <s$all& there is in!ol$ntar& prote%ti!e splintin) of the %orrespon in) spinal se)#ents '& refle+ a%ti!it& in para!erte'ral #$s%les" an %ertain #o!e#ents or post$res that %o$ntera%t the spas# an alter the position of the in.$re tiss$es ten to a))ra!ate the pain( Also" the s$perfi%ial str$%t$res in the in!ol!e re)ion are ten er an ire%t press$re on the# e!o-es pain( M$s%les that

are %ontin$all& in refle+ spas# #a& also 'e%o#e ten er an sensiti!e to eep press$re( Referre pain is of two t&pes" one that is pro.e%te fro# the spine to !is%era an other str$%t$res l&in) within the territor& of the l$#'ar an $pper sa%ral er#ato#es an another that is pro.e%te fro# pel!i% an a' o#inal !is%era to the spine( Pain $e to isease of the $pper part of the l$#'ar spine is often referre to the flan-" lateral hip" )roin" an anterior thi)h( This has 'een attri'$te to irritation of the s$perior %l$neal ner!es" whi%h are eri!e fro# the posterior i!isions of the first three l$#'ar spinal ner!es an inner!ate the s$perior portions of the '$tto%-s( Pain fro# the lower part of the l$#'ar spine is $s$all& referre to the lower '$tto%-s an posterior thi)hs an is $e to irritation of lower spinal ner!es" whi%h a%ti!ate the sa#e pool of intraspinal ne$rons as the ner!es that inner!ate the posterior thi)hs( Pain of this t&pe is $s$all& rather iff$se an has a eep" a%hin) ,$alit&" '$t it ten s at ti#es to 'e #ore s$perfi%iall& pro.e%te ( M%Call an %ollea)$es an Kell)ren ha!e !erifie these areas of referen%e '& the in.e%tion of h&pertoni% saline into the apoph&seal .oints( B$t" as Sin%lair an %owor-ers ha!e pointe o$t" the sites of referen%e are ine+a%t an %annot 'e relie $pon for the pre%ise anato#i% lo%ali=ation of lesions( In )eneral" the intensit& of the referre pain parallels that of the lo%al pain( In other wor s" #ane$!ers that alter lo%al pain ha!e a si#ilar effe%t on referre pain" tho$)h la%-in) the pre%ision an i##e ia%& of so3 %alle root pain( Pain fro# !is%eral iseases is $s$all& felt within the a' o#en" flan-s" or l$#'ar re)ion an #a& 'e #o ifie '& the state of a%ti!it& of the !is%era an so#eti#es '& ass$#in) an $pri)ht or s$pine post$re( Its %hara%ter an te#poral relationships ha!e little relationship to #o!e#ent of the 'a%-( Ra i%$lar" or >root"? pain has so#e of the %hara%teristi%s of referre pain '$t iffers in its )reater intensit&" istal ra iation" %ir%$#s%ription to the territor& of a root" an fa%tors that e+%ite it( The #e%hanis# is stret%hin)" irritation" or %o#pression of a spinal root" within or %entral to the inter!erte'ral fora#en( The pain is sharp" often intense" an $s$all& s$peri#pose on the $ll a%he of referre pain6 it nearl& alwa&s ra iates fro# a para%entral position near the spine to so#e part of the lower li#'( Co$)hin)" snee=in)" an strainin) %hara%teristi%all& e!o-e this sharp ra iatin) pain" altho$)h ea%h of these a%tions #a& also .ar or #o!e the spine an enhan%e lo%al pain6 .$)$lar !ein %o#pression" whi%h raises intraspinal press$re an #a& %a$se a shift in position of the root" has a si#ilar effe%t( In fa%t" an& #ane$!er that stret%hes the ner!e root@e()(" >strai)ht3le) raisin)? in %ases of s%iati%a@e!o-es ra i%$lar pain( The patterns of ra i%$lar pain $e to in!ol!e#ent of parti%$lar roots are es%ri'e in the se%tions on prolapse is%s /pa)es 42A an 44B544C0( The #ost %o##on pattern is s%iati%a" pain that ori)inates in the '$tto%- an is pro.e%te alon) the posterior or posterolateral thi)h( It res$lts fro# irritation of the LB or S2 ner!e root( Paresthesias or s$perfi%ial sensor& loss" soreness of the s-in" an ten erness in %ertain %ir%$#s%ri'e re)ions alon) the ner!e $s$all& a%%o#pan&

ra i%$lar pain( If the anterior roots are in!ol!e as well" there #a& 'e refle+ loss" wea-ness" atroph&" an fas%i%$lar twit%hin)( In patients with se!ere %ir%$#ferential %onstri%tion of the %a$ a e,$ina $e to spon &losis /l$#'ar stenosis0" sensori#otor i#pair#ent an so#eti#es referre pain are eli%ite '& stan in) an wal-in)( The ne$rolo)i% s&#pto#s in!ol!e the %al!es an the 'a%- of the thi)hs" si#$latin) the e+er%ise3in $%e s&#pto#s $e to !as%$lar ins$ffi%ien%&@hen%e the ter# spinal %la$ i%ation /see pa)e 42D0( Of i#portan%e is the o'ser!ation that referre pain fro# the lower 'a%- /so#eti#es %alle pse$ ora i%$lar0 oes not" as a r$le" pro.e%t 'elow the -nees an is not a%%o#panie '& ne$rolo)i% %han)es other than a !a)$e n$#'ness witho$t e#onstra'le sensor& i#pair#ent( The s$'%$taneo$s tiss$es within the area of referre pain #a& 'e ten er( Of %o$rse" lo%al" referre " an ra i%$lar pain #a& o%%$r to)ether( Pain res$ltin) fro# #$s%$lar spas# $s$all& o%%$rs in relation to lo%al pain( The spas# #a& 'e tho$)ht of as a no%ifensi!e refle+ for the prote%tion of the isease parts a)ainst in.$rio$s #otion( M$s%le spas# is asso%iate with #an& isor ers of the low 'a%- an %an istort nor#al post$re( Chroni% #$s%$lar %ontra%tion #a& )i!e rise to a $ll" so#eti#es %ra#pin) a%he( One %an feel the ta$tness of the sa%rospinalis an )l$teal #$s%les an e#onstrate '& palpation that the pain is lo%ali=e to the#( Howe!er" e+%ept for the #ost se!ere e)rees of spas# in a%$te in.$r& of the 'a%-" the %ontri'$tion of this %o#ponent to 'a%- pain is relati!el& s#all( Other pains" often of $n eter#ine ori)in" are so#eti#es es%ri'e '& patients with %hroni% isease of the lower part of the 'a%-; rawin) an p$llin) in the le)s" %ra#pin) sensation /witho$t in!ol$ntar& #$s%le spas#0" tearin)" thro''in)" or .a''in) pains" an feelin)s of '$rnin) or %ol ness( These sensations" li-e paresthesias an n$#'ness" sho$l alwa&s s$))est the possi'ilit& of ner!e or root isease( In a ition to assessin) the %hara%ter an lo%ation of the pain" one sho$l eter#ine the fa%tors that a))ra!ate an relie!e it" its %onstan%&" an its relationship to a%ti!it& an rest" post$re" forwar 'en in)" an %o$)h" snee=e" an strain( 1re,$entl& the #ost i#portant lea %o#es fro# -nowle )e of the #o e of onset an the %ir%$#stan%es that initiate the pain( Inas#$%h as #an& painf$l affe%tions of the 'a%- are the res$lt of in.$ries in%$rre $rin) wor- or in a$to#o'ile a%%i ents" the possi'ilit& of e+a))eration or prolon)ation of pain for p$rposes of %o#pensation #$st alwa&s 'e -ept in #in ( E+a#ination of the Lower Ba%So#e infor#ation #a& 'e )aine '& inspe%tion of the 'a%-" '$tto%-s" an lower li#'s in !ario$s positions( The nor#al spine shows a thora%i% -&phosis an l$#'ar

lor osis in the sa)ittal plane" whi%h in so#e in i!i $als #a& 'e e+a))erate /swa&'a%-0( In the %oronal plane" the spine is nor#all& strai)ht or shows a sli)ht %$r!at$re" parti%$larl& in wo#en( One sho$l o'ser!e the spine %losel& for e+%essi!e %$r!at$re" a list" flattenin) of the nor#al l$#'ar lor osis" presen%e of a )i''$s /a sharp" -&photi% an)$lation $s$all& in i%ati!e of a fra%t$re0" pel!i% tilt or o'li,$it& /Tren elen'$r) si)n0" an as&##etr& of the para!erte'ral or )l$teal #$s%$lat$re( A sa))in) )l$teal fol s$))ests in!ol!e#ent of the S2 root( In s%iati%a one #a& o'ser!e a fle+e post$re of the affe%te le)" pres$#a'l& to re $%e tension on the irritate ner!e( Patients in who# a free fra)#ent of l$#'ar is% #aterial has #i)rate posterolaterall& #a& 'e $na'le to lie own an e+ten the spine( The ne+t step in the e+a#ination is o'ser!ation of the spine" hips" an le)s $rin) %ertain #otions( It is well to re#e#'er that no a !anta)e a%%r$es fro# eter#inin) how #$%h pain the patient %an tolerate( More i#portant is to eter#ine when an $n er what %on itions the pain 'e)ins or worsens( O'ser!ation of the patient*s )ait when he is $naware of 'ein) wat%he #a& is%lose a s$'tle li#p" a pel!i% tilt" a shortenin) of step" or a stiffness of 'earin)@in i%ati!e of a isin%lination to 'ear wei)ht on a painf$l le)( One loo-s for li#itation of #otion while the patient is stan in)" sittin)" an re%linin)( When stan in)" the #otion of forwar 'en in) nor#all& pro $%es flattenin) an re!ersal of the l$#'ar lor oti% %$r!e an e+a))eration of the thora%i% %$r!e( With lesions of the l$#'osa%ral re)ion that in!ol!e the posterior li)a#ents" arti%$lar fa%ets" or sa%rospinalis #$s%les an with r$pt$re l$#'ar is%s" prote%ti!e refle+es pre!ent fle+ion" whi%h stret%hes these str$%t$res( As a %onse,$en%e" the sa%rospinalis #$s%les re#ain ta$t an pre!ent #otion in the l$#'ar part of the spine( 1orwar 'en in) then o%%$rs at the hips an at the thora%ol$#'ar .$n%tion6 also" the patient 'en s in s$%h a wa& as to a!oi tensin) the ha#strin) #$s%les an p$ttin) $n $e le!era)e on the pel!is( In the presen%e of e)enerati!e is% isease" strai)htenin) $p fro# a fle+e position is perfor#e with iffi%$lt& an is ai e to so#e e+tent '& fle+in) the -nees( Lateral 'en in) is $s$all& less instr$%ti!e than forwar 'en in)( In $nilateral li)a#ento$s or #$s%$lar strain" 'en in) to the opposite si e a))ra!ates the pain '& stret%hin) the a#a)e tiss$es( With $nilateral s%iati%a" the patient lists to one si e an stron)l& resists 'en in) to the opposite si e" an his preferre post$re in stan in) is with the le) sli)htl& fle+e at the hip an -nee( When the herniate is% lies lateral to the ner!e root an ispla%es it #e iall&" tension on the root is re $%e '& 'en in) the tr$n- to the si e opposite the lesion6 with herniation #e ial to the root" tension is re $%e '& in%linin) the tr$n- to the si e of the lesion( In the sittin) position" fle+ion of the spine %an 'e perfor#e #ore easil&" e!en to the point of 'rin)in) the -nees in %onta%t with the %hest( The reason for this is that -nee fle+ion rela+es ti)htene ha#strin) #$s%les an relie!es the stret%h on the s%iati% ner!e( As-in) the seate patient to e+ten the le) so that the sole of the foot %an 'e inspe%te is a wa& of %he%-in) for a fei)ne LasE)$e si)n /see 'elow0(

E+a#ination in the re%linin) position &iel s #$%h the sa#e infor#ation as in the stan in) an sittin) positions( With l$#'osa%ral is% lesions an s%iati%a" passi!e l$#'ar fle+ion %a$ses little pain an is not li#ite as lon) as the ha#strin)s are rela+e an there is no stret%hin) of the s%iati% ner!e( Th$s" with the -nees fle+e to F8 e)rees" sittin) $p fro# the re%linin) position is $ni#pe e an not painf$l6 with -nees e+ten e " there is pain an li#ite #otion /Kra$s3We'er test0( With !erte'ral isease /e()(" arthritis0" passi!e fle+ion of the hips is free" whereas fle+ion of the l$#'ar spine #a& 'e i#pe e an painf$l( Passi!e strai)ht3le) raisin) /possi'le $p to F8 e)rees in nor#al in i!i $als0" li-e forwar 'en in) in the stan in) post$re with the le)s strai)ht" pla%es the s%iati% ner!e an its roots $n er tension" there'& pro $%in) ra i%$lar ra iatin) pain( It #a& also %a$se an anterior rotation of the pel!is aro$n a trans!erse a+is" in%reasin) stress on the l$#'osa%ral .oint an %a$sin) pain if this .oint is arthriti% or otherwise isease ( Conse,$entl&" in iseases of the l$#'osa%ral .oints an roots" passi!e strai)ht3le) raisin) e!o-es pain an is li#ite on the affe%te si e an " to a lesser e+tent" on the opposite si e /LasE)$e si)n0( Strai)ht raisin) of the opposite le) #a& also %a$se pain on the affe%te si e an is 'elie!e '& so#e to 'e an e!en #ore relia'le si)n of prolapse is% than a LasE)$e si)n( It is i#portant to re#e#'er that the e!o-e pain is alwa&s referre to the isease si e" no #atter whi%h le) is ele!ate ( While in the s$pine position" le) len)th /anteros$perior ilia% spine to #e ial #alleol$s0 an the %ir%$#feren%e of the thi)h an %alf sho$l 'e #eas$re ( H&pere+tension #a& 'e perfor#e with the patient stan in) or l&in) prone( If the %on ition %a$sin) 'a%- pain is a%$te" it #a& 'e iffi%$lt to e+ten the spine in the stan in) position( A patient with l$#'osa%ral strain or is% isease /e+%ept in the a%$te phase or if the is% fra)#ent has #i)rate laterall&0 %an $s$all& e+ten or h&pere+ten the spine with little or no a))ra!ation of pain( If there is an a%ti!e infla##ator& pro%ess or fra%t$re of the !erte'ral 'o & or posterior ele#ents" h&pere+tension #a& 'e #ar-e l& li#ite ( In isease of the $pper l$#'ar roots" h&pere+tension is the #otion that is li#ite an repro $%es pain6 howe!er" in so#e %ases of lower l$#'ar is% isease with thi%-enin) of the li)a#ent$# fla!$#" this #o!e#ent is also painf$l( In patients with narrowin) of the spinal %anal /spon &losis" spon &lolisthesis0" $pri)ht stan%e an e+tension #a& pro $%e ne$rolo)i% s&#pto#s /see f$rther on0( Mane$!ers in the lateral e%$'it$s position &iel less infor#ation as a r$le( In %ases of sa%roilia% .oint isease" a' $%tion of the $psi e le) a)ainst resistan%e repro $%es pain in the sa%roilia% re)ion" with ra iation of the pain to the '$tto%-" posterior thi)h" an s&#ph&sis p$'is( H&pere+tension of the $psi e le) with the ownsi e le) fle+e is another test for sa%roilia% isease( Rotation an a' $%tion of the le) e!o-e pain in a isease hip .oint an with tro%hanteri% '$rsitis( Another helpf$l in i%ator of hip pain is the Patri%- test; with the patient s$pine" the heel of the offen in) le) is pla%e on the opposite -nee an pain is e!o-e '& epressin) the fle+e le) an e+ternall& rotatin) the hip(

:entle palpation an per%$ssion of the spine are the last steps in the e+a#ination( It is prefera'le to first palpate the re)ions that are the least li-el& to e!o-e pain( At all ti#es the e+a#iner sho$l -now what str$%t$res are 'ein) palpate /see 1i)( 223 G0( Lo%ali=e ten erness is sel o# prono$n%e in isease of the spine 'e%a$se the in!ol!e str$%t$res are so eep( Ne!ertheless" ten erness o!er a spino$s pro%ess or .arrin) '& )entle per%$ssion #a& in i%ate the presen%e of infla##ation /as in is% spa%e infe%tion0" patholo)i% fra%t$re" a spinal #etastasis" or a is% lesion at the site eep to it(

1i)$re 223G /20 Costo!erte'ral an)le( /40 Spino$s pro%ess an interspino$s li)a#ent( /G0 Re)ion of arti%$lar fa%et /fifth l$#'ar to first sa%ral0( /A0 Dors$# of sa%r$#( /B0 Re)ion of ilia% %rest( /C0 Iliol$#'ar an)le( /70 Spino$s pro%esses of fifth l$#'ar an first sa%ral !erte'rae /ten erness H fa$lt& post$re or o%%asionall& spina 'ifi a o%%$lta0( /D0 Re)ion 'etween posterior s$perior an posterior inferior spines( Sa%roilia% li)a#ents /ten erness H sa%roilia% sprain" often ten er with fifth l$#'ar or first sa%ral is%0( /F0 Sa%ro%o%%&)eal .$n%tion /ten erness H sa%ro%o%%&)eal in.$r&" i(e(" sprain or fra%t$re0( /280 Re)ion of sa%ros%iati% not%h /ten erness H fo$rth or fifth l$#'ar is% r$pt$re an sa%roilia% sprain0( /220 S%iati% ner!e tr$n/ten erness H r$pt$re l$#'ar is% or s%iati% ner!e lesion0(

Ten erness o!er the %osto!erte'ral an)le often in i%ates )enito$rinar& isease" a renal isease" or an in.$r& to the trans!erse pro%ess of the first or se%on l$#'ar !erte'ra I1i)( 223G" /20J( Ten erness on palpation of the paraspinal #$s%les #a& si)nif& a strain of #$s%le atta%h#ents or in.$r& to the $n erl&in) trans!erse pro%esses of the l$#'ar !erte'rae( 1o%al pain in the sa#e sa)ittal line alon) the thora%i% spine points to infla##ation of the %ostotrans!erse arti%$lation 'etween spine an ri' /%ostotrans!ersitis0( In palpatin) the spino$s pro%esses" it is i#portant to note an& e!iation in the lateral plane /this #a& 'e in i%ati!e of fra%t$re or arthritis0 or in the anteroposterior plane( A >step3off? forwar ispla%e#ent of the spino$s pro%ess an e+a))erate lor osis are i#portant %l$es to the presen%e of spon &lolisthesis /see f$rther on0( Ten erness o!er the interspino$s li)a#ents is in i%ati!e of is% lesions I1i)( 223G" /40J( Ten erness o!er the re)ion of the arti%$lar fa%ets 'etween the fifth l$#'ar an first sa%ral !erte'rae is %onsistent with l$#'osa%ral is% isease I1i)( 223G" /G0J(

Ten erness in this re)ion an in the sa%roilia% .oints is also a fre,$ent #anifestation of an-&losin) spon &litis( A' o#inal" re%tal" an pel!i% e+a#inations are essential ele#ents in the st$ & of the patient with low 'a%- s&#pto#s that fail to 'e %larifie '& the afore#entione spinal #ane$!ers( Neoplasti%" infla##ator&" or e)enerati!e isor ers #a& pro $%e s&#pto#s referre to the lower part of the spine( <pon %o#pletion of the e+a#ination of the 'a%- an le)s" one t$rns to a sear%h for #otor" refle+" an sensor& %han)es in the lower e+tre#ities /see >Protr$sion of L$#'ar Inter!erte'ral Dis%s"? f$rther on in this %hapter0( An%illar& Dia)nosti% Pro%e $res Depen in) on the %ir%$#stan%es" these #a& in%l$ e a 'loo %o$nt an er&thro%&te se i#entation rate /espe%iall& helpf$l in s%reenin) for infe%tion or #&elo#a06 %al%i$#" phosphor$s" $ri% a%i " al-aline phosphatase" a%i phosphatase" an prostate3spe%ifi% anti)en /if one s$spe%ts #etastati% %ar%ino#a of the prostate06 a ser$# protein ele%trophoresis /#&elo#a proteins06 in spe%ial %ases" a t$'er%$lin test or serolo)i% test for Br$%ella6 a test for rhe$#atoi fa%tor6 an HLA t&pin) /for an-&losin) spon &litis0( Ra io)raphs of the l$#'ar spine /prefera'l& with the patient stan in)0 in the anteroposterior" lateral" an o'li,$e planes are still $sef$l in the ro$tine e!al$ation of low 'a%- pain an s%iati%a( Rea il& e#onstra'le in plain fil#s are narrowin) of the inter!erte'ral is% spa%es" 'on& fa%etal or !erte'ral o!er)rowth" ispla%e#ent of !erte'ral 'o ies /spon &lolisthesis0" an an $ns$spe%te infiltration of 'one '& %an%er( In %ases of s$spe%te is% herniation or t$#or infiltration of the spinal %anal" one pro%ee s ire%tl& to MRI( Altho$)h these i#a)in) pro%e $res ha!e lar)el& repla%e %on!entional #&elo)raph&" the latter e+a#ination" when %o#'ine with %o#p$te to#o)raph& /CT0" pro!i es etaile infor#ation a'o$t the $ral slee!es that s$rro$n the spinal roots" at ti#es is%losin) s$'tle tr$n%ations %a$se '& laterall& sit$ate is% herniations an at ti#es re!ealin) s$rfa%e a'nor#alities of the spinal %or " s$%h as arterio!eno$s #alfor#ations( A #inistration of )a olini$# at the ti#e of MRI enhan%es re)ions of infla##ation an t$#or( In.e%tion of %ontrast #e i$# ire%tl& into the inter!erte'ral is% / is%o)ra#0 is still pra%ti%e in a few instit$tions '$t is #ore iffi%$lt to interpret than CT3#&elo)raph& an MRI an %arries the ris- of a#a)e to ner!e roots or the intro $%tion of infe%tion( Dis%o)raph& is in i%ate onl& in spe%ial %ir%$#stan%es an sho$l 'e $n erta-en onl& '& those who are spe%iali=e in its perfor#an%e( Isotope 'one s%ans are $sef$l in e#onstratin) t$#ors an infla##ator& pro%esses s$%h as osteo#&elitis( Ner!e %on $%tion st$ ies an ele%tro#&o)raph& /EM:0 are parti%$larl& helpf$l in s$spe%te root an ner!e iseases" as in i%ate f$rther on in the is%$ssion of protr$ e l$#'ar is%s( Howe!er" as for all the afore#entione tests" the& are

$sef$l onl& in the %onte+t of the histor& an %lini%al e+a#ination6 otherwise the& are s$'.e%t to o!er$se an o!erinterpretation( Prin%ipal Con itions :i!in) Rise to Pain in the Lower Ba%Con)enital Ano#alies of the L$#'ar Spine Anato#i% !ariations of the spine are fre,$ent" an tho$)h rarel& of the#sel!es the so$r%e of pain an f$n%tional eran)e#ent" the& #a& pre ispose an in i!i $al to is%o)eni% an spon &loti% %o#pli%ations '& !irt$e of alterin) the #e%hani%s an ali)n#ent of the !erte'rae or si=e of the spinal %anal( The %o##onest ano#al& is a la%- of f$sion of the la#inae of one or se!eral of the l$#'ar !erte'rae or of the sa%r$# /spina 'ifi a0( O%%asionall&" a s$'%$taneo$s #ass" h&pertri%hosis" or h&perpi)#entation in the sa%ral area 'etra&s the %on ition" '$t in #ost patients it re#ains o%%$lt $ntil it is is%lose ra iolo)i%all&( The ano#al& #a& 'e a%%o#panie '& #alfor#ation of !erte'ral .oints an $s$all& in $%es pain onl& when a))ra!ate '& in.$r&( The ne$rolo)i% aspe%ts of efe%ti!e f$sion of the spine / &sraphis#0 are is%$sse in Chap( GD( Man& other %on)enital ano#alies affe%t the lower l$#'ar !erte'rae; as&##etri%al fa%etal .oints" a'nor#alities of the trans!erse pro%esses" >sa%rali=ation? of the fifth l$#'ar !erte'ra /in whi%h LB appears to 'e fi+e to the sa%r$#0" or >l$#'ari=ation? of the first sa%ral !erte'ra /in whi%h S2 loo-s li-e a si+th l$#'ar !erte'ra0 are seen o%%asionall& in patients with low 'a%- s&#pto#s" '$t apparentl& with no )reater fre,$en%& than in as&#pto#ati% in i!i $als( The role of these ano#alies in the )enesis of low 'a%- eran)e#ent is $n%lear" '$t in the a$thors* opinion the& are rarel& the %a$se of spe%ifi% s&#pto#s( Spon &lol&sis %onsists of a 'on& efe%t in the pars interarti%$laris /the se)#ent at the .$n%tion of pe i%le an la#ina0 of the lower l$#'ar !erte'rae( The efe%t is re#ar-a'l& %o##on6 it affe%ts appro+i#atel& B per%ent of the North A#eri%an pop$lation" is pro'a'l& )eneti%" an pre isposes to fra%t$re at this lo%ation( Ra io)raphi%all&" the pars interarti%$laris efe%t is 'est !is$ali=e on o'li,$e pro.e%tions( In so#e persons it is $nilateral an #a& %a$se $nilateral a%hin) 'a%pain that is a%%ent$ate '& h&pere+tension an twistin)( It is not $n%o##on in athletes( In the $s$al 'ilateral for#" s#all fra%t$res at the pars interarti%$laris allow the !erte'ral 'o &" pe i%les" an s$perior arti%$lar fa%ets to #o!e anteriorl&" lea!in) the posterior ele#ents 'ehin ( This latter efor#it&" -nown as spon &lolisthesis" is #ainl& a isease of %hil ren /pea- in%i en%e 'etween B an 7 &ears of a)e0( It #a& %a$se little iffi%$lt& at first '$t e!ent$all& 'e%o#es s&#pto#ati%( The patient %o#plains of li#itation of #otion an pain in the low 'a%-" ra iatin) into the thi)hs( E+a#ination is%loses ten erness near the se)#ent that has >slippe ? /#ost often LB" o%%asionall& LA0" a palpa'le >step? of the spino$s pro%ess forwar fro# the se)#ent 'elow" ha#strin) spas#" an " in se!ere %ases /spon &loptosis0" shortenin) of the tr$n- an protr$sion of the lower a' o#en /'oth

of whi%h res$lt fro# the a'nor#al forwar shift of LB on S20 as well as si)ns of in!ol!e#ent of spinal roots@paresthesias an sensor& loss" #$s%le wea-ness" an refle+ i#pair#ent( These ne$rolo)i% s&#pto#s an si)ns ten not to 'e se!ere( So#eti#es" the fo$rth l$#'ar !erte'ra #a& slip forwar on the fifth" narrowin) the spinal %anal" witho$t the presen%e of a efe%t in the pars interarti%$laris( This is ter#e inta%t ar%h spon &lolisthesis an o%%$rs #ost often in #i le3a)e or el erl& wo#en( This for# of spon &lolisthesis is pro'a'l& $e to e)enerati!e isease of the inferior an s$perior fa%ets( It %a$ses se!ere low 'a%- pain" #a e worse '& stan in) or wal-in) an relie!e '& 'e rest( S&#pto#s of root %o#pression are %o##on /Ale+an er et al0( Patients with pro)ressi!e !erte'ral ispla%e#ent an ne$rolo)i% efi%its re,$ire s$r)er&" $s$all& posterolateral f$sion an e+%ision of the posterior ele#ents( Re $%tion of ispla%e !erte'ral 'o ies 'efore f$sion an ire%t repair of pars efe%ts are possi'le in spe%ial %ases( Tra$#ati% Disor ers of the Low Ba%- Tra$#ati% isor ers %onstit$te the #ost fre,$ent %a$se of low 'a%- pain( In se!ere a%$te in.$ries" the e+a#iner #$st 'e %aref$l to a!oi f$rther a#a)e( All #o!e#ents #$st 'e -ept to a #ini#$# $ntil an appro+i#ate ia)nosis has 'een #a e an a e,$ate #eas$res ha!e 'een instit$te for the proper %are of the patient( If the patient %o#plains of pain in the 'a%- an %annot #o!e his le)s" the spine #a& ha!e 'een fra%t$re an the %or or %a$ a e,$ina %o#presse or %r$she ( The ne%- sho$l not 'e #anip$late " an the patient sho$l not 'e allowe to sit $p( /See Chap( AA for f$rther is%$ssion of spinal %or in.$r&(0 Sprains an Strains The ter#s l$#'osa%ral strain" sprain" an eran)e#ent are $se loosel& '& #ost ph&si%ians" an it is pro'a'l& not possi'le to ifferentiate the#( What was for#erl& referre to as >sa%roilia% strain? or >sprain? is now -nown to 'e $e" in #an& instan%es" to is% isease( The a$thors prefer the ter# a%$te low 'a%- or #&ofas%ial strain for #inor" self3li#ite in.$ries that are $s$all& asso%iate with liftin) hea!& loa s in a #e%hani%all& isa !anta)e position" a fall" stiffness that arises fro# prolon)e $n%o#forta'le post$res s$%h as air tra!el or %ar ri es" or s$ en $ne+pe%te #otion" as #a& o%%$r in an a$to a%%i ent( The is%o#fort of a%$te low3'a%- strain is often se!ere" an the patient #a& ass$#e $n$s$al post$res relate to spas# of the lower l$#'ar an sa%rospinalis #$s%les( The pain is $s$all& %onfine to the lower part of the 'a%-" in the #i line or .$st to one si e or other of the spine( The ia)nosis of l$#'osa%ral strain epen s $pon the es%ription of the in.$r& or a%ti!it& that pre%ipitate the pain" the lo%ali=ation of the pain" the fin in) of lo%ali=e ten erness" the a$)#entation of pain '& post$ral %han)es" e()(" 'en in) forwar " twistin)" or stan in) $p fro# a sittin) position" an the a'sen%e of si)ns of ra i%$lar in!ol!e#ent( In #ore than D8

per%ent of %ases of a%$te low3'a%- strain of this t&pe" the pain resol!es in a #atter of se!eral a&s or a wee- e!en with no spe%ifi% treat#ent( Sa%roilia% strain is the #ost li-el& ia)nosis when there is ten erness o!er the sa%roilia% .oint an pain ra iatin) to the '$tto%- an posterior thi)h" '$t this alwa&s nee s to 'e istin)$ishe fro# a r$pt$re inter!erte'ral is% /see f$rther on0( Strain is %hara%teristi%all& worsene '& a' $%tion of the thi)h a)ainst resistan%e an is also felt in the s&#ph&sis p$'is or )roin( It" too" respon s within a&s or a wee- or two to %onser!ati!e #ana)e#ent( Treat#ent of A%$te Low3Ba%- Strains The pain of #$s%$lar an li)a#ento$s strains is $s$all& self3li#ite " respon in) to si#ple #eas$res in a relati!el& short perio of ti#e( The 'asi% prin%iple of therap& in 'oth isor ers is rest" in a re%$#'ent position" for se!eral a&s( L&in) on the si e with -nees an hips fle+e or s$pine with a pillow $n er the -nees are the fa!ore positions( With strains of the sa%rospinalis #$s%les an sa%roilia% li)a#ents" the opti#al position is h&pere+tension( This position is 'est #aintaine '& ha!in) the patient lie with a s#all pillow or fol e 'lan-et $n er the l$#'ar portion of the spine or '& l&in) fa%e own( Ph&si%al #eas$res@s$%h as appli%ation of i%e in the a%$te phase /G8 #in on" C8 #in off0 an heat after the thir or fo$rth a&" iather#&" an #assa)e@%an 'e trie '$t are of li#ite !al$e( Nonsteroi al anti3infla##ator& #e i%ation sho$l 'e )i!en li'erall& $rin) the first few a&s( M$s%le rela+ants are of little $se" ser!in) #ainl& to #a-e 'e rest #ore tolera'le( When wei)ht 'earin) is res$#e " is%o#fort #a& 'e i#inishe '& a li)ht l$#'osa%ral s$pport" '$t #an& orthope ists refrain fro# pres%ri'in) this ai ( Thereafter" %orre%ti!e e+er%ises are pres%ri'e " esi)ne to stret%h an stren)then tr$n- /espe%iall& a' o#inal0 #$s%les" o!er%o#e fa$lt& post$re" an in%rease the #o'ilit& of the spinal .oints( The $se of spinal #anip$lation@pra%ti%e '& %hiropra%tors" osteopaths" an others @has alwa&s 'een a %ontentio$s #atter in the <nite States" partl& 'e%a$se of $nrealisti% therape$ti% %lai#s #a e in iseases other than low 'a%- eran)e#ents( B& %ontrast" in %ertain parts of E$rope" orthope ists often in%orporate #anip$lati!e pro%e $res into %on!entional pra%ti%e( A t&pe of slow #$s%le stret%hin) an .oint istra%tion /a+ial tra%tion on a .oint0 a #inistere '& ph&siatrists is ,$ite si#ilar( It #$st 'e re%o)ni=e that #an& patients see- %hiropra%ti% #anip$lation on their own" often 'efore seein) a ph&si%ian" an #a& not is%lose this infor#ation to the ph&si%ian( When the s$pportin) ele#ents of the spine /pe i%les" fa%ets" an li)a#ents0 are not isr$pte " %hiropra%ti% #anip$lation of the l$#'ar spine has pro!i e relief to a %onsi era'le n$#'er of patients with low3'a%- strain or fa%et pain( A ran o#i=e British trial has shown #anip$lation to 'e s$perior to anal)esi%s an 'e rest in ret$rnin) patients to wor- after #inor 'a%- in.$r& /Mea e et al0( So#e trials ha!e %orro'orate this fin in) /Ha ler et al0" while others ha!e not or the res$lts ha!e 'een a#'i)$o$s( In the st$ & '& Cher-in an %ollea)$es %o#parin) %hiropra%ti%" ph&si%al therap& /M%Ken=ie #etho 0" an si#ple instr$%tion to the patient fro# a 'oo-let" #anip$lation &iel e a sli)htl& 'etter o$t%o#e at the

en of a #onth( Despite se!eral h&potheses that ha!e 'een offere '& pra%titioners of spinal #anip$lation" the #e%hanis# of pain relief is not -nown( The so$n %reate '& rapi an for%ef$l istra%tion of the fa%et .oints" si#ilar to %ra%-in) the -n$%-les" see#s not to 'e ne%essar& for pain relief( Whether all for#s of low3'a%pain represent #inor s$'l$+ations" as %lai#e '& %hiropra%tors" is $n o%$#ente an see#s $nli-el&( Chroni% low 'a%- pain has" in the a$thors* e+perien%e" 'een e!en less s$%%essf$ll& treate '& #anip$lati!e pro%e $res" '$t there are patients who testif& to i#pro!e#ent in their %lini%al state" an a #itte l& the #e i%al profession has little to offer #an& of these patients( The %o##it#ent of patients to a re)i#e of anti3infla##ator& a)ents for #an& #onths or to nar%oti% anal)esi%s is a ha=ar alwa&s to 'e a!oi e ( The De)enerati!e Low3Ba%- S&n ro#e Often the s&#pto#s of low3'a%- strain are re%$rrent an #ore %hroni% in nat$re" 'ein) re)$larl& e+a%er'ate '& 'en in) or liftin)" s$))estin) that post$ral" #$s%$lar" an arthriti% fa%tors pla& a role( This is the #ost %o##on s&n ro#e seen in orthope i% %lini%s" #ore in #en than in wo#en( After so#e $n$s$al a%ti!it&" raisin) the ,$estion of tra$#a" espe%iall& if it happens in the wor-pla%e" the patient e!elops eep a%hin) pain in the low 'a%-" in%rease '& %ertain #o!e#ents an atten e '& stiffness( The pain often has a restri%te ra iation into the '$tto%-s an posterior thi)h( There are no #otor" sensor&" or refle+ a'nor#alities( Plain fil#s an i#a)in) pro%e $res re!eal so#e %o#'ination of osteoarthropath&" %han)es in !erte'ral is%s" osteoarthriti% %han)es in apoph&seal .oints" an so#eti#es osteoporosis or sli)ht spon &losis( Treat#ent with short3 $ration 'e rest" anal)esi%s" an ph&siotherap&" as o$tline for a%$te strains" help to relie!e the s&#pto#s an the #a.orit& of patients re%o!er within a #onth( Chiropra%ti% #anip$lation has the sa#e $n%ertain effe%t as for a%$te low3 'a%- s&#pto#s( <s$all& the ori)in of the pain %annot 'e eter#ine an spe%ial ia)nosti% pro%e $res are not helpf$l( Onl& if the pain persists for lon)er than a #onth is MRI in i%ate ( Re%$rrent atta%-s are t&pi%al of e)enerati!e spine isease( Wor-ers* %o#pensation pro'le#s a to the isa'ilit&" espe%iall& in ol er wor-ers( Kerte'ral 1ra%t$res 1ra%t$res of a l$#'ar !erte'ral 'o & are $s$all& the res$lt of fle+ion in.$ries( S$%h tra$#a #a& o%%$r in a fall or .$#p fro# a hei)ht /if the patient lan s on his feet" the %al%anei #a& also 'e fra%t$re 0 or as a res$lt of an a$to a%%i ent or other !iolent in.$r&( If the in.$r& is se!ere" it #a& %a$se a fra%t$re islo%ation" a >'$rst? fra%t$re of one or #ore !erte'ral 'o ies" or an as&##etri%al fra%t$re of a pe i%le" la#ina" or spino$s pro%ess" '$t #ost often there is as&##etri%al loss of hei)ht of a !erte'ral 'o & /%o#pression fra%t$re0" whi%h #a& 'e e+tre#el& painf$l at the onset( When %o#pression or other fra%t$res o%%$r with #ini#al tra$#a /or spontaneo$sl&0" the 'one has pres$#a'l& 'een wea-ene '& so#e patholo)i% pro%ess( Most of the ti#e" parti%$larl& in ol er in i!i $als" osteoporosis is the %a$se of s$%h an e!ent" '$t there are #an& other %a$ses" in%l$ 3 in) osteo#ala%ia" h&perparath&roi is#" prolon)e $se of %orti%osteroi s" an-&losin)

spon &litis" #&elo#a" #etastati% %ar%ino#a" an a n$#'er of lo%al %on itions( Spas# of the lower l$#'ar #$s%les" li#itation of all #o!e#ents of the l$#'ar se%tion of the spine" an the ra io)raphi% appearan%e of the a#a)e l$#'ar portion /with or witho$t ne$rolo)i% a'nor#alities0 are the 'asis of %lini%al ia)nosis( The pain is $s$all& i##e iate" tho$)h o%%asionall& it #a& 'e ela&e for a&s( A fra%t$re trans!erse pro%ess" whi%h is al#ost alwa&s asso%iate with tearin) of the para!erte'ral #$s%les an a lo%al he#ato#a" %a$ses eep ten erness at the site of the in.$r&" lo%al #$s%le spas#" an li#itation of all #o!e#ents that stret%h the l$#'ar #$s%les( The ra iolo)i% fin in)s" parti%$larl& MRI" %onfir# the ia)nosis( In so#e %ir%$#stan%es" tears of the para!erte'ral #$s%$lat$re #a& 'e asso%iate with e+tensi!e 'lee in) into the retroperitoneal spa%e an pro+i#al le) wea-ness( Herniation of L$#'ar Inter!erte'ral Dis%s This %on ition is a #a.or %a$se of se!ere an %hroni% or re%$rrent low 'a%- an le) pain( It o%%$rs #ainl& $rin) the thir an fo$rth e%a es of life" when the n$%le$s p$lpos$s is still )elatino$s( The is% 'etween the fifth l$#'ar an first sa%ral !erte'rae /LB3S20 is the one #ost often in!ol!e " an " with e%reasin) fre,$en%&" that 'etween the fo$rth an fifth /LA3B0" thir an fo$rth /LG3A0" se%on an thir /L43G0" an ,$ite infre,$entl&" the first an se%on /L2340 l$#'ar !erte'rae( Relati!el& rare '$t well es%ri'e in the thora%i% portion of the spine" is% isease is a)ain fre,$ent at the fifth an si+th an the si+th an se!enth %er!i%al !erte'rae /see f$rther on0( The %a$se of a herniate l$#'ar is% is $s$all& a fle+ion in.$r&" '$t a %onsi era'le proportion of patients o not re%all a tra$#ati% episo e( De)eneration of the n$%le$s p$lpos$s" the posterior lon)it$ inal li)a#ents" an the ann$l$s fi'ros$s #a& ha!e ta-en pla%e silentl& or ha!e 'een #anifest '& #il " re%$rrent l$#'ar a%he( A snee=e" l$r%h" or other tri!ial #o!e#ent #a& then %a$se the n$%le$s p$lpos$s to prolapse" p$shin) the fra&e an wea-ene ann$l$s posteriorl&( 1ra)#ents of the n$%le$s p$lpos$s protr$ e thro$)h rents in the ann$l$s" $s$all& to one si e or the other /so#eti#es in the #i line0" where the& i#pin)e $pon a root or roots( In #ore se!ere %ases of is% isease" the n$%le$s #a& protr$ e thro$)h the ann$l$s or 'e e+tr$ e an lie epi $rall&" as a free fra)#ent( A lar)e protr$sion #a& %o#press the root/s0 a)ainst the arti%$lar apoph&sis or la#ina( The protr$ e #aterial #a& 'e resor'e to so#e e+tent an 'e%o#e re $%e in si=e" '$t often it oes not" %a$sin) %hroni% irritation of the root or a is%arthrosis with posterior osteoph&te for#ation( The Clini%al S&n ro#e The f$ll& e!elope s&n ro#e of prolapse inter!erte'ral l$#'ar is% %onsists of; /20 pain in the sa%roilia% re)ion" ra iatin) into the '$tto%-" thi)h" %alf" an foot an 'roa l& ter#e s%iati%a6 /40 a stiff or $nnat$ral spinal post$re6 an /G0 so#e %o#'ination of paresthesias" wea-ness" an refle+ i#pair#ent(

The pain of herniate inter!erte'ral is% !aries in se!erit& fro# a #il is%o#fort to the #ost se!ere -nife3li-e sta's that ra iate the len)th of the le) an are s$peri#pose on a %onstant intense a%he( A'orti!e for#s of s%iati%a #a& pro $%e a%hin) is%o#fort onl& in the lower '$tto%- an thi)h an o%%asionall& onl& in the lower ha#strin) or $pper %alf( With the #ost se!ere pain" the patient is for%e to sta& in 'e " a!oi in) the sli)htest #o!e#ent6 a %o$)h" snee=e" or strain is intolera'le( The patient is $s$all& #ost %o#forta'le l&in) on his 'a%- with le)s fle+e at the -nees an hips / orsal e%$'it$s position0 an with the sho$l ers raise on pillows to o'literate the l$#'ar lor osis( 1or so#e patients" a parti%$lar lateral e%$'it$s position is #ore %o#forta'le( As #entione earlier" free fra)#ents of is% that fin their wa& to a lateral an posterior position in the spinal %anal #a& pro $%e the opposite sit$ation" one of 'ein) $na'le to e+ten the spine an lie s$pine( When the %on ition is less se!ere" wal-in) is possi'le" tho$)h fati)$e sets in ,$i%-l&" with a feelin) of hea!iness an rawin) pain( Sittin) an stan in) $p fro# a sittin) position are parti%$larl& painf$l( The pain is $s$all& lo%ate eep in the '$tto%-" .$st lateral to an 'elow the sa%roilia% .oint" an in the posterolateral re)ion of the thi)h" with ra iation to the %alf an infre,$entl& to the heel an other parts of the foot( Ra iation of pain into the foot sho$l at least raise the s$spi%ion of an alternati!e %a$se of ner!e a#a)e( It is noteworth& an s$rprisin) to patients that a l$#'ar is% protr$sion so#eti#es %a$ses little 'a%- pain" altho$)h in these %ir%$#stan%es there is often" in o$r e+perien%e" eep ten erness o!er the lateral pro%ess or fa%et .oint a .a%ent to the protr$sion( Pain is also %hara%teristi%all& pro!o-e '& press$re o!er the %o$rse of the s%iati% ner!e at the %lassi% points of Kallei+ /s%iati% not%h" retrotro%hanteri% )$tter" posterior s$rfa%e of thi)h" hea of fi'$la0( Press$re at one point #a& %a$se ra iation of pain an tin)lin) own the le)( Elon)ation of the ner!e root '& strai)ht3le) raisin) or '& fle+in) the le) at the hip an e+ten in) it at the -nee /LasE)$e #ane$!er0 is the #ost %onsistent of all pain3 pro!o-in) si)ns( When s%iati%a is se!ere" strai)ht3le) raisin) is restri%te to 48 to G8 e)rees of ele!ation6 when the %on ition is less se!ere or with i#pro!e#ent" the an)le for#e '& the le) an 'e wi ens" finall& to al#ost F8 e)rees" in patients with fle+i'le 'a%-s an li#'s( D$rin) strai)ht3le) raisin)" the patient %an istin)$ish 'etween the is%o#fort of or inar& ta$tness of the ha#strin) an the sharper" less fa#iliar root pain" parti%$larl& when as-e to %o#pare the e+perien%e with that on the nor#al si e( Man& !ariations of the LasE)$e #ane$!er ha!e 'een es%ri'e /all with epon&#s0" the #ost $sef$l of whi%h is a%%ent$ation of the pain '& orsifle+ion of the foot /Bra)ar si)n0 or of the )reat toe /Si%ar si)n0( The LasE)$e #ane$!er with the health& le) #a& e!o-e pain" '$t $s$all& of lesser e)ree an alwa&s on the si e of the spontaneo$s pain /1a.ersta)n si)n0( The presen%e of a %rosse strai)ht3 le)3raisin) si)n is stron)l& in i%ati!e of a r$pt$re is% as the %a$se of s%iati%a /in BC of BD %ases in the series of H$ )-ins0( With the patient stan in)" forwar 'en in) of the tr$n- will %a$se fle+ion of the -nee on the affe%te si e /Neri si)n06 the e)ree of li#itation of forwar 'en in) appro+i#ates that of strai)ht3le) raisin)( S%iati%a #a& 'e pro!o-e '& for%e fle+ion of the hea an ne%-" %o$)hin)"

or press$re on 'oth .$)$lar !eins" all of whi%h in%rease the intraspinal press$re /Naff=i)er si)n0( Mar-e in%onsisten%ies in response to these tests raise the s$spi%ion of ps&%holo)i% fa%tors( In the $pri)ht position" the post$re of the 'o & is altere '& the pain( The patient stan s with the affe%te le) sli)htl& fle+e at the -nee an hip" so that onl& the 'all of the foot rests on the floor( The tr$n- ten s to tilt forwar an to one si e or the other" epen in) on the relationship of the protr$ e is% #aterial to the root /see a'o!e0( This antal)i% post$re is referre to as s%iati% s%oliosis an is #aintaine '& refle+ %ontra%tion of the paraspinal #$s%les" whi%h %an 'e 'oth seen an palpate ( In wal-in)" the -nee is sli)htl& fle+e " an wei)ht 'earin) on the painf$l le) is 'rief an %a$tio$s" )i!in) a li#p( It is parti%$larl& painf$l for the patient to )o $p an own stairs( The si)ns of se!ere spinal root %o#pression are i#pair#ent of sensation" loss or i#in$tion of ten on refle+es" an #$s%le wea-ness( The h&potonia is e!i ent on inspe%tion an palpation of the '$tto%- an %alf" an the A%hilles ten on ten s to 'e less salient( Paresthesias /rarel& h&peresthesia or h&poesthesia0 are reporte '& one3thir of patients6 $s$all& the& are felt in the foot" so#eti#es in the le)( Often there is a i#in$tion of pain per%eption o!er the appropriate er#ato#e( M$s%le wea-ness o%%$rs" '$t less fre,$entl&( The an-le or -nee .er- is $s$all& i#inishe or lost on the si e of the lesion( The refle+ %han)es ha!e little relationship to the se!erit& of the pain or sensor& loss( 1$rther#ore" %o#pression of the fo$rth or fifth l$#'ar root #a& o%%$r witho$t an& %han)e in the ten on refle+es( Bilateralit& of s&#pto#s an si)ns is rare" as is sphin%teri% paral&sis" '$t the& #a& o%%$r with lar)e %entral protr$sions( The %ere'rospinal fl$i /CS10 protein is then pre i%ta'l& ele!ate " $s$all& in the ran)e of BB to DB #)L L" so#eti#es hi)her( As in i%ate a'o!e" herniations of the inter!erte'ral l$#'ar is%s o%%$r #ost often 'etween the fifth l$#'ar an first sa%ral !erte'rae /%o#pressin) the S2 root6 see 1i) 223A0 an 'etween the fo$rth an fifth l$#'ar !erte'rae /%o#pressin) the LB root0( It is i#portant" therefore" to re%o)ni=e the %lini%al %hara%teristi%s of root %o#pression at these two sites( Lesions of the fifth l$#'ar root pro $%e pain in the re)ion of the hip" posterolateral thi)h" lateral %alf /to the e+ternal #alleol$s0" orsal s$rfa%e of the foot" an the first or se%on an thir toes( Paresthesias #a& 'e felt in the entire territor& or onl& in its istal parts( The ten erness is in the lateral )l$teal re)ion an near the hea of the fe#$r( Wea-ness" if present" in!ol!es the e+tensors of the 'i) toe an of the foot( The an-le .er- #a& 'e i#inishe /#ore often it is nor#al0" '$t the -nee .er- is har l& e!er altere ( Wal-in) on the heels #a& 'e #ore iffi%$lt an $n%o#forta'le than wal-in) on the toes 'e%a$se of wea-ness of orsifle+ion(

1i)$re 223A Me%hanis#s of %o#pression of the fifth l$#'ar an first sa%ral roots( A lateral is% protr$sion at the LA3B le!el $s$all& in!ol!es the fifth l$#'ar root an spares the fo$rth6 a protr$sion at LB3S2 in!ol!es the first sa%ral root an spares the fifth l$#'ar root( Note that a #ore #e iall& pla%e is% protr$sion at the LA3B le!el /%ross3hat%he 0 #a& in!ol!e the fifth l$#'ar root as well as the first /or se%on an thir 0 sa%ral root(

With lesions of the first sa%ral root" the pain is felt in the #i )l$teal re)ion" posterior part of the thi)h" posterior re)ion of the %alf to the heel" o$ter plantar s$rfa%e of the foot" an fo$rth an fifth toes( Ten erness is #ost prono$n%e o!er the #i )l$teal re)ion /in the re)ion of the sa%roilia% .oint0" posterior thi)h areas" an %alf( Paresthesias an sensor& loss are #ainl& in the lower part of the le) an o$ter toes" an wea-ness" if present" in!ol!es the fle+or #$s%les of the foot an toes" a' $%tors of the toes" an ha#strin) #$s%les( The A%hilles refle+ is i#inishe or a'sent in the #a.orit& of %ases( In fa%t" loss of the A%hilles refle+ is often the first an onl& o'.e%ti!e si)n( Wal-in) on the toes is #ore iffi%$lt an $n%o#forta'le than wal-in) on the heels 'e%a$se of wea-ness of the plantar fle+ors( The rarer lesions of the thir an fo$rth l$#'ar roots )i!e rise to pain in the anterior part of the thi)h an -nee an antero#e ial part of the le) /fo$rth l$#'ar0" with %orrespon in) sensor& i#pair#ent( The -nee .er- is i#inishe or a'olishe ( LG #otor root lesions #a& wea-en the ,$a ri%eps" thi)h a $%tor" an iliopsoas6 LA root lesions wea-en the anterior ti'ial inner!ate #$s%les( L2 root pain is pro.e%te to the )roin an L4 to the lateral hip( Motion of the spine an %ertain positions are #ost e!o%ati!e of root pain6 if the pain is %onstant in all positions" root irritation is sel o# the %a$se( M$%h has 'een #a e of a istin%ti!e s&n ro#e asso%iate with e+tre#e lateral is% protr$sions" parti%$larl& those l&in) within the pro+i#al portion of the inter!erte'ral spinal fora#ina( <nre#ittin) ra i%$lar pain witho$t 'a%- pain an a ten en%& to worsen with e+tension of the 'a%- an torsion towar the si e of the herniation are sai to 'e %hara%teristi%( Si#ilarl&" in rare instan%es of l$#'ar intra $ral is% r$pt$re" there #a& not 'e s%iati% pain 'e%a$se the free fra)#ent oes not i#pin)e on the roots of the %a$ a e,$ina( Both of these %onfi)$rations #a& %onfo$n ra iolo)i% ia)nosis an #a-e s$r)er& #ore iffi%$lt( Rarer still are protr$sions of thora%i% inter!erte'ral is%s /8(B per%ent of all s$r)i%all& !erifie is% protr$sions" a%%or in) to Lo!e an S%horn0( The fo$r

lower#ost thora%i% interspa%es are the #ost fre,$entl& in!ol!e ( Tra$#a" parti%$larl& har falls on the heels or '$tto%-s" is an i#portant %a$sati!e fa%tor( Deep 'orin) spine pain" root pain %ir%lin) the 'o & or pro.e%te to the a' o#en or thora+ /so#eti#es si#$latin) !is%eral isease0" paresthesias 'elow the le!el of the lesion" loss of sensation" 'oth eep an s$perfi%ial" an paraparesis or paraple)ia are the $s$al %lini%al #anifestations( 1re,$entl&" a herniate is% at one interspa%e %o#presses #ore than one root /1i)( 223A0" an it follows that the s&#pto#s will then refle%t this in!ol!e#ent( Ano#alies of the l$#'osa%ral roots #a& lea to errors in lo%ali=ation /see es%riptions '& Posta%%ini et al0( The %o#'ine r$pt$re of two or #ore is%s o%%$rs o%%asionall& an f$rther %o#pli%ates the %lini%al pi%t$re( When 'oth the LB an S2 roots are %o#presse '& a lar)e herniate is%" the si)ns of the S2 lesion $s$all& pre o#inate( Low3'a%- pain #a& also 'e %a$se '& e)eneration of the inter!erte'ral is%" witho$t fran- e+tr$sion of is% tiss$e" or '& e)enerati!e arthriti% %han)es of the spine" es%ri'e f$rther on" $n er l$#'ar spon &losis( Or the herniation #a& o%%$r into the a .a%ent !erte'ral 'o &" )i!in) rise to a so3%alle S%h#orl no $le( In s$%h %ases there are no si)ns of ner!e root in!ol!e#ent" altho$)h 'a%- pain #a& 'e present" so#eti#es re%$rrent an referre to the thi)h( An not to 'e for)otten as a %a$se of low3'a%- pain is the i#pli%ation of a root or ner!e '& an intrinsi% t$#or( Dia)nosis When all %o#ponents of the s&n ro#e are present" ia)nosis is eas&6 '$t #ost ne$rolo)ists prefer to %orro'orate their %lini%al i#pression '& CT" with or witho$t %ontrast #&elo)raph&" or '& MRI of the LG3S2 spine( Most ne$rolo)ists fa!or MRI" in part 'e%a$se of the a !anta)es of the sa)ittal i#a)e6 howe!er" the ifferen%es are sli)ht e+%ept when the e+tr$ e fra)#ent is #ol e into the a .a%ent 'one /as it is prone to 'e with laterall& e+tr$ e fra)#ents0 an 'e%o#es ine!i ent on CT /see 1orristall et al0( As in i%ate earlier" we t$rn to CT3 #&elo)raph& for refine efinition of the root slee!es an $se the EM: to %orro'orate s$'tle fin in)s( <s$all& MRI will e#onstrate the e+tr$ e is% at the s$spe%te site an will also e+%l$ e herniations at other sites or an $ns$spe%te t$#or /1i)( 223B0( At the l$#'osa%ral .$n%tion there is a wi e )ap 'etween the posterior #ar)ins of the !erte'rae an the $ral sa%" so that a lateral or %entral protr$sion of the LB3S2 is% #a& fail to istort the $ral #ar)in as seen on #&elo)raph&( In this sit$ation /an in others where the is% is not e!i ent0" ner!e %on $%tion st$ ies an ele%tro#&o)raph& are $sef$l( We fin " as o Le&shon an %owor-ers" that the nee le st$ & in parti%$lar is a'nor#al showin) fi'rillation potentials in ener!ate #$s%les after one or two wee-s in o!er F8 per%ent of %ases( Loss or #ar-e as&##etr& of the H refle+ is a parti%$larl& $sef$l si)n of S2 ra i%$lopath&( The fin in) of ener!ation potentials in the paraspinal #$s%les /in i%atin) root rather than peripheral ner!e lesions0 an in other #$s%les in a root istri'$tion is also helpf$l" pro!i e that at least 4 or G wee-s ha!e elapse fro# the onset of root pain(

1i)$re 223B L$#'ar is% herniation on T32 wei)hte MRI( A( Sa)ittal !iew of lar)e LB3S2 herniate n$%le$s p$lposis /arrow0( The e+tr$ e #aterial has the sa#e si)nal %hara%teristi%s as the nor#al a .a%ent is%( B( A+ial !iew of sa#e is% /arrow0 showin) the para%entral #ass that o'literates the epi $ral fat si)nal an %o#presses the S2 root(

It is #ost i#portant to -eep in #in that a n$#'er of is% a'nor#alities" fre,$entl& o'ser!e on MRI an loosel& referre to as >herniation"? #a& 'e in%i ental fin in)s" $nrelate to the patient*s s&#pto#s( 9ensen an %ollea)$es" in an MRI st$ & of the l$#'ar spine in FD as&#pto#ati% a $lts" fo$n that in #ore than half of the# there was a s&##etri%al e+tension of a is% /or is%s0 'e&on the #ar)ins of the interspa%e /'$l)in)0( In 47 per%ent" there was a fo%al or as&##etri%al e+tension of the is% 'e&on the interspa%e /protr$sion0" an in onl& 2 per%ent was there #ore e+tre#e e+tension of the is% /e+tr$sion0( These fin in)s e#phasi=e the i#portan%e of $sin) pre%ise #orpholo)i% ter#s in es%ri'in) the MRI a'nor#alities an alwa&s e!al$atin) these a'nor#alities in the li)ht of the patient*s s&#pto#s( Mana)e#ent of R$pt$re L$#'ar Dis% In the treat#ent of an a%$te or %hroni% r$pt$re of a l$#'ar is%" %o#plete 'e rest is $s$all& a !ise an appears to 'e helpf$l" altho$)h e!en this ti#e3honore tenet has 'een ,$estione '& the res$lts of a ran o#i=e st$ & /Kroo#en et al0( Nonetheless we a here to this for# of treat#ent an it res$lts in #ar-e i#pro!e#ent in o!er D8 per%ent of patients( Anal)esi% #e i%ation" either nonsteroi al anti3infla##ator& a)ents or nar%oti%s" #a& 'e re,$ire for a few a&s( In so#e patients with se!ere s%iati%a" we ha!e 'een i#presse with the relief affor e '& a #inistration of oral e+a#ethasone for se!eral a&s" A #) e!er& D h" altho$)h this has not 'een st$ ie s&ste#ati%all&( The onl& in i%ation for e#er)en%& s$r)er& is an a%$te %o#pression of the %a$ a e,$ina '& #assi!e is% e+tr$sion" %a$sin) 'ilateral sensori#otor loss an sphin%teri% paral&sis or se!ere $nilateral #otor loss( Altho$)h not the re%o##en e %o$rse for #ost patients" it sho$l 'e pointe o$t that there are instan%es where e!en a ra#ati% s&n ro#e of %a$ a e,$ina %o#pression has %leare $p after se!eral wee-s of 'e rest( Tra%tion is of little !al$e in l$#'ar is% isease" an it is 'est to per#it the patient to fin the #ost %o#forta'le position( After 2 or 4 wee-s at rest" the patient %an 'e allowe to res$#e a%ti!ities )ra $all&"

so#eti#es with the prote%tion of a 'ra%e or li)ht spinal s$pport( The patient #a& s$ffer #inor re%$rren%e of the pain '$t sho$l 'e a'le to %ontin$e his $s$al a%ti!ities an e!ent$all& will re%o!er( If the pain an ne$rolo)i% fin in)s o not s$'si e in response to this t&pe of %onser!ati!e #ana)e#ent or the patient s$ffers fre,$ent isa'lin) a%$te episo es" s$r)i%al treat#ent #$st 'e %onsi ere ( This sho$l 'e pre%e e '& CT3 #&eolo)raph& or MRI to lo%ali=e the lesion /an e+%l$ e intra3 or e+tra $ral t$#ors0( The s$r)i%al pro%e $re #ost often in i%ate for l$#'ar is% isease is a he#ila#ine%to#&" with e+%ision of the is% in!ol!e ( In %ases with s%iati% pain $e to LA3B or LB3S2 is% r$pt$res" DB to F8 per%ent are relie!e '& operation( Rer$pt$re o%%$rs in appro+i#atel& B per%ent /Shannon an Pa$l0( Arthro esis /spinal f$sion0 of the in!ol!e se)#ents is in i%ate onl& in %ases in whi%h there is e+traor inar& insta'ilit&" $s$all& relate to an anato#i% a'nor#alit& /s$%h as spon &lol&sis0( The treat#ent of ner!e root %o#pression with repeate epi $ral in.e%tions of #eth&lpre nisolone en.o&e a perio of pop$larit&" '$t %ontrolle st$ ies of this pro%e $re ha!e faile to %onfir# its s$staine effi%a%& /White et al6 C$%-ler et al0 an the pro%e $re is not witho$t %o#pli%ations( Carette et al ha!e fo$n onl& short3 ter# i#pro!e#ent with fa%et in.e%tion" '$t the $lti#ate nee for s$r)er& was not altere /see f$rther on0( Ne!ertheless" #an& ne$rolo)ists ha!e not is%ar e this for# of treat#ent in !iew of nota'le s$%%ess in sele%te patients( Che#on$%leol&sis has 'een $se for the #ana)e#ent of l$#'ar is% lesions6 howe!er" as e+perien%e with this pro%e $re in%rease " so i the n$#'er of fail$res an a !erse effe%ts" an the pro%e $re has 'een a'an one ( The sa#e is tr$e for the intra $ral in.e%tion of #eth&lpre nisolone( Other Ca$ses of S%iati%a an Low3Ba%- Pain An in%reasin) e+perien%e with l$#'ar 'a%- pain" )l$teal ne$ral)ia" an s%iati%a has i#presse the a$thors with the lar)e n$#'er of s$%h %ases that are $nsol!a'le( At one ti#e all these %ases were %lassifie as s%iati% ne$ritis or >sa%roilia% strain(? After Mi+ter an Barr pop$lari=e the %on%ept of prolapse is%" all s%iati%a an l$#'ar pains were as%ri'e to this %on ition( Operations 'e%a#e wi el& pra%ti%e " not onl& for fran- is% protr$sion '$t also for >har is%s? /$nr$pt$re 0 an relate patholo)ies of the spine( The s$r)i%al res$lts 'e%a#e less an less satisfa%tor& $ntil re%entl&" in lar)e referral %enters" as #an& patients were 'ein) seen with $nrelie!e postla#ine%to#& pain as with $noperate r$pt$re is%s( To e+plain these %hroni% pain %ases" a n$#'er of new patholo)i% entities" so#e of $n%ertain stat$s" ha!e 'een es%ri'e ( Entrap#ent of l$#'ar roots appears to 'e the %onse,$en%e not onl& of is% r$pt$re '$t also of spon &loti% sp$rs with stenosis of the lateral re%ess" h&pertroph& of apoph&seal fa%ets" %o#pression of the ner!e '& the p&rifor#is #$s%le" an ara%hnoi itis( Lateral re%ess stenosis in parti%$lar #a& 'e a %a$se of s%iati%a not relie!e '& is% s$r)er&( Another s$rprisin) fin in) in the %o$rse of i#a)in) the spinal %anal is a %&st3li-e ilatation of the perine$rial sheath

/Tarlo! %&sts0( One or #ore sa%ral roots #a& 'e in!ol!e at points where the& penetrate the $ra an 'e asso%iate with ra i%$lar s&#pto#s( There are reports of relief fro# openin) the %&sts an freein) the roots( S%iati%a that is te#porall& lin-e to the pre#enstr$al perio is not $n%o##on an is al#ost alwa&s $e to en o#etriosis that in!ol!es the ner!e at the s%iati% not%h( We ha!e also o'ser!e %ases of s%iati%a that o%%$rre with ea%h pre)nan%&( These are '$t a few of the lar)e n$#'er of spinal a'nor#alities is%lose '& newer ra iolo)i% te%hni,$es( An atlas of these a'nor#alities@%on)enital an e!elop#ental stenoses" Pa)et isease" apoph&seal .oint a'nor#alities in%l$ in) s&no!ial %&sts arisin) fro# the .oint" $nilateral spon &lolisthesis" tro%hanteri% an is%hio)l$teal '$rsitis@are a #ira'l& presente in the s&#posi$# on CT of the l$#'ar spine /see Referen%es" $n er >S&#posi$#?0( Co#pression of the %a$ a e,$ina '& epi $ral t$#or" as es%ri'e f$rther on" #ost often 'e)ins with 'a%- pain or s%iati%a" #ost often as a res$lt of eposits of prostati% or 'reast %an%er or #&elo#a( The s%iati% ner!e or the ple+$s fro# whi%h it ori)inates #a& 'e i#pli%ate in t$#or )rowths /l&#pho#a" ne$rofi'rosar%o#a0( Se!eral infla##ator& iseases of the %a$ a e,$ina pro $%e 'a%- pain an 'ilateral s%iati%a an #a& 'e #ista-en for the #ore $s$al t&pes of %a$ a e,$ina %o#pression@%&to#e)alo!ir$s infe%tion in AIDS patients" L&#e isease" herpeti% infe%tion" an neoplasti% #enin)itis at ti#es 'eha!e in this fashion( In all of these" the CS1 shows an intense pleo%&tosis( The :$illain3BarrM s&n ro#e #a& also pro $%e #islea in) 'a%- an ra i%$lar pain 'efore wea-ness is apparent( The %a$ al roots in these iseases enhan%e with )a olini$# on MRI( 1inall& one #$st not o!erloo- the possi'le o%%$rren%e of a l$#'osa%ral ple+$s ne$ritis" a $nilateral /o%%asionall& 'ilateral0 isor er a-in to 'ra%hial ne$ritis" an a%$te or s$'a%$te s%iati% or fe#oral ne$ropath& $e to ia'etes" herpes =oster" or a retroperitoneal #ass" an& of whi%h #a& pro $%e a s&n ro#e si#ilar to that of r$pt$re is% /see Chap( AC0( L$#'ar Stenosis an Spon &loti% Ca$ al Ra i%$lopath& In the l$#'ar re)ion" osteoarthriti% or spon &loti% %han)es #a& lea to %o#pression of one or #ore %a$ al roots( The pro'le# is e+a))erate if there is a %on)enitall& narrow l$#'ar %anal( The roots are %a$)ht 'etween the posterior s$rfa%e of the !erte'ral 'o & an the li)a#ent$# fla!$# posterolaterall&( Lateral re%ess stenosis" all$ e to a'o!e" #a& also %ontri'$te to root %o#pression( <pon stan in) or wal-in) / ownhill wal-in) is espe%iall& iffi%$lt0" there is in #an& %ases a )ra $al onset of n$#'ness an wea-ness of the le)s" whi%h for%es the patient to sit own( When this %on ition is #ore se!ere" the patient )ains relief '& s,$attin) or l&in) own with the le)s fle+e at the hips an -nees( <s$all& the n$#'ness 'e)ins in one le)" sprea s to the other" an as%en s as stan in) or wal-in) %ontin$es( Ten on refle+es #a& isappear" onl& to ret$rn on fle+in) the spine( Pain in the low 'a%- an )l$teii is !aria'le( Dist$r'an%es of #i%t$rition an i#poten%e are rare( In so#e patients with

l$#'ar stenosis" ne$rolo)i% s&#pto#s persist witho$t relation to 'o & position( The %lini%al pi%t$re" with its inter#itten%&" %orrespon s to the so3%alle inter#ittent %la$ i%ation of the %a$ a e,$ina es%ri'e '& !an :el eren in 2FAD( Soon thereafter" it was shown '& Ker'iest to 'e $e not to is%he#ia '$t to en%roa%h#ent on the %a$ a '& h&pertrophie apoph&seal .oints" thi%-ene li)a#ents" an s#all protr$sions of is% #aterial en)rafte $pon a %anal that is e!elop#entall& shallow in the anteroposterior ia#eter( So#eti#es a sli)ht s$'l$+ation at LG3A or at LA3B is also present( Later it 'e%a#e e!i ent that the %anal in these %ases is also narrow fro# si e to si e /re $%e interpe i%$lar istan%e ra io)raphi%all&0( De%o#pression of the spinal %anal relie!es the s&#pto#s in a %onsi era'le proportion of the %ases( Spon &loti% %a$ al ra i%$lopath& is the l$#'ar e,$i!alent of spon &loti% %er!i%al #&elopath& an ra i%$lopath&( Insofar as the for#er is a %a$ a e,$ina s&n ro#e" its ifferential ia)nosis is also is%$sse in Chap( AA" >Diseases of the Spinal Cor (? Osteoarthritis or Osteoarthropath& This" the #ost fre,$ent t&pe of arthriti% isease" $s$all& o%%$rs in later life an #a& in!ol!e all or an& part of the spine( Howe!er" it is #ost pre!alent in the %er!i%al an l$#'ar re)ions" where it is so#eti#es %onf$se with is%o)eni% s&n ro#es( The pain is %entere in the affe%te part of the spine" is in%rease '& #o!e#ent" an is asso%iate with stiffness an li#itation of #otion( There is a nota'le a'sen%e of s&ste#i% s&#pto#s s$%h as fati)$e" #alaise" an fe!er" an the pain %an $s$all& 'e relie!e '& rest( A sli)htl& fle+e post$re is preferre ( The sittin) position is $s$all& %o#forta'le" altho$)h stiffness an is%o#fort are a%%ent$ate when the ere%t post$re is res$#e ( There are no ne$rolo)i% si)ns e+%ept in asso%iation with is% isease( The se!erit& of the s&#pto#s often 'ears little relation to the ra iolo)i% fin in)s6 pain #a& 'e present espite #ini#al ra io)raphi% fin in)s6 %on!ersel&" #ar-e osteoph&ti% o!er)rowth with sp$r for#ation" ri )in)" 'ri )in) of !erte'rae" narrowin) of is% spa%es" s$'l$+ation of posterior .oints on fle+ion" an air in the is% spa%es %an 'e seen in 'oth s&#pto#ati% an as&#pto#ati% persons( The 1a%et S&n ro#e This s&n ro#e has 'een %larifie in re%ent &ears" '$t its efinition is still so#ewhat i#pre%ise( It appears that two istin%t painf$l states %an 'e relate to isease of the fa%et .oint an a .a%ent lateral re%ess( In one t&pe" fa%et h&pertroph& )i!es rise to a l$#'ar #onora i%$lopath&" in istin)$isha'le fro# that $e to a r$pt$re is%( Re&nol s et al ha!e o%$#ente 44 s$%h %ases( Of these patients" 2C ha an LB ra i%$lopath&" G an S2 ra i%$lopath&" an G an LA ra i%$lopath&6 in 2B of the patients there was %oe+istin) 'a%- pain( At operation" the spinal root was %o#presse a)ainst the floor of the inter!erte'ral %anal '& o!er)rowth of an inferior or s$perior fa%et( 1ora#inoto#& an fa%ete%to#&" after e+ploration of the root fro# the $ral sa% to the pe i%le" relie!e the pain in 24 of the 2B operate %ases( In a se%on t&pe" fa%et h&pertroph& )i!es rise to l$#'ar 'a%- pain" often parasa)ittal" so#eti#es in the #i line" with !aria'le ten erness o!er the .oint '$t

witho$t si)ns of root %o#pression6 it is relie!e for a !aria'le perio '& in.e%tion of the .oint with li o%aine or its eri!ati!es( Often one is $n%ertain whether it was the anal)esi% effe%t on the .oint or the infiltration of the re)ion aro$n the ner!e root that relie!e the pain( Two %ontrolle st$ ies ha!e pro!i e e!i en%e of the ineffi%a%& of another pop$lar treat#ent for this t&pe of low3'a%- pain" na#el&" %orti%osteroi in.e%tions into the fa%et .oints /Carette et al6 Lili$s et al0( Notwithstan in) these st$ ies" we ha!e fo$n the in.e%tion of anal)esi%s an steroi s in an aro$n the fa%et to 'e a $sef$l te#pori=in) #eas$re in so#e patients( In an& %ase" this )ro$p of patients oes not re,$ire operation( L$#'ar A hesi!e Ara%hnoi itis This also is a so#ewhat !a)$e entit&" in whi%h the ara%hnoi #e#'rane is thi%-ene an opa,$e in the !i%init& of the %a$ a e,$ina( The ter# is also applie to thi%-enin) of the ara%hnoi al sheaths aro$n roots /roots ha!e essentiall& no epine$ri$#0( It %an 'e seen in l$#'ar #&elo)ra#s in whi%h the %ontrast #aterial fails to o$tline the roots an flow freel& in the s$'ara%hnoi spa%e( A%%or in) to a British re!iew" l$#'ar ara%hnoi itis is rare" ha!in) 'een seen in onl& D8 of 7C88 #&elo)ra#s( 9$ )in) '& A#eri%an writin)s" it is #$%h #ore fre,$ent /see >S&#posi$#"? in the Referen%es0( The $s$al %lini%al feat$res are intra%ta'le low3'a%- an le) pain an paresthesias" all positional" in %o#'ination with ne$rolo)i% a'nor#alities refera'le to l$#'ar spinal roots( In o$r patients" #$ltiple #&elo)ra#s" is% r$pt$re" operati!e pro%e $res" infe%tions" an s$'ara%hnoi 'lee in) ha!e 'een %a$sall& in!ol!e ( So#e %ases ha!e followe spinal anesthesia an e!en epi $ral anesthesia '& a perio of #onths or &ears( The pres$#ption is that the $ra ha 'een 'rea%he an often there were %lini%al si)ns of an asepti% #enin)itis soon after the pro%e $re( The MRI #a& show e%%entri%all& thi%-ene #enin)es in the spinal %anal with ara%hnoi a hesions an %olle%tions of CS1 that ispla%e ner!e roots /1i)( 223C0( Treat#ent is $nsatisfa%tor&( L&sis of a hesions an a #inistration of intrathe%al steroi s ha!e 'een of no !al$e( Epi $ral in.e%tion of steroi s is o%%asionall& helpf$l" a%%or in) to so#e orthope ists(

1i)$re 223C Se!ere l$#'ar ara%hnoi itis %a$sin) 'a%- pain" s%iati%a" an paresthesias &ears after spinal anal)esia( L$#'ar MRI perfor#e with inf$sion of )a olini$# showin) thi%-ene ara%hnoi an ispla%e#ent of %a$ a e,$ine roots '& a%,$ire ara%hnoi %&sts(

An-&losin) Spon &litis This isor er" referre to in the past as rhe$#atoi spon &litis an as !on Be%hterew or Marie3Str$#pell arthritis" affe%ts &o$n) a $lt #ales pre o#inantl&( Its pre!alen%e in the )eneral pop$lation has 'een !ario$sl& esti#ate at 2 to G per 2888( Appro+i#atel& FB per%ent of patients with an-&losin) spon &litis are #ar-e '& the histo%o#pati'ilit& anti)en HLA3B47 /whi%h is present in onl& 7 per%ent of nonaffe%te persons0( Pain" $s$all& %entere in the low 'a%-" is the #ain %o#plaint" at least in the initial sta)es of the isease( Often it ra iates to the 'a%- of the thi)hs an )roin( At first the s&#pto#s are !a)$e /tire 'a%-" >%at%hes? $p an own the 'a%-" sore 'a%-0" an the ia)nosis #a& 'e o!erloo-e for #an& &ears( Altho$)h the pain is re%$rrent" li#itation of #o!e#ent is %onstant an pro)ressi!e6 o!er ti#e" it o#inates the %lini%al pi%t$re( Earl& in the %o$rse" this is e+perien%e as >#ornin) stiffness? or an in%rease in stiffness after perio s of ina%ti!it&6 these fin in)s #a& 'e present lon) 'efore ra iolo)i% %han)es are #anifest( Rarel&" a %a$ a e,$ina s&n ro#e #a& %o#pli%ate an-&losin) spon &litis" the res$lt apparentl& of an infla##ator& rea%tion an later a proliferation of %onne%ti!e tiss$e in the %a$ al %anal /Matthews0( Li#itation of %hest e+pansion" ten erness o!er the stern$#" e%rease #otion an ten en%& to pro)ressi!e fle+ion of the hips" an the %hara%teristi% i##o'ilit& an fle+ion efor#it& of the spine />po-er spine?0 #a& 'e present earl& in the %o$rse of the isease( The ra iolo)i% hall#ar-s are" at first" estr$%tion an s$'se,$entl& o'literation of the sa%roilia% .oints" followe '& 'on& 'ri )in) of the !erte'ral 'o ies to pro $%e the %hara%teristi% >'a#'oo spine(? When this o%%$rs" the pain $s$all& s$'si es" '$t the patient has '& then little #otion of the 'a%- an ne%-( An-&losin) spon &litis #a& also 'e a%%o#panie '& the Reiter s&n ro#e" psoriasis" an infla##ator& iseases of the intestine /see also Chap( AA0( The )reat ris- in this isease is fra%t$re islo%ation of the spine fro# relati!el& #inor tra$#a" parti%$larl& fle+ion3e+tension in.$ries( O%%asionall& an-&losin) spon &litis is %o#pli%ate '& estr$%ti!e !erte'ral lesions( This %o#pli%ation sho$l 'e s$spe%te whene!er the pain ret$rns after a perio of ,$ies%en%e or 'e%o#es lo%ali=e ( The %a$se of these lesions is not -nown" '$t the& #a& represent a response to non$nion of fra%t$res" ta-in) the for# of an e+%essi!e pro $%tion of fi'ro$s infla##ator& tiss$e( An-&losin) spon &litis" when se!ere" #a& in!ol!e 'oth hips" )reatl& a%%ent$atin) the 'a%- efor#it& an isa'ilit&( Rhe$#atoi arthritis" when it affe%ts the spine" #a& 'e %onfine to the %er!i%al re)ion an is %onsi ere f$rther on in this %hapter( Neoplasti% an Infe%tio$s Diseases of the Spine Metastati% %ar%ino#a /'reast" 'ron%h$s" prostate" th&roi " -i ne&" sto#a%h" $ter$s0" #$ltiple #&elo#a" an l&#pho#a are the %o##on #ali)nant t$#ors that in!ol!e the spine( The pri#ar& lesion #a& 'e s#all an as&#pto#ati% an the first #anifestation of the t$#or #a& 'e pain in the 'a%- $e to #etastati% eposits( The pain is es%ri'e as %onstant an $ll6 it is often $nrelie!e '& rest an #a& 'e worse at ni)ht( Ra i%$lar pain #a& 'e a e " as es%ri'e earlier in the %hapter( At the ti#e of onset of the 'a%-

pain" there #a& 'e no ra io)raphi% %han)es6 when s$%h %han)es o appear" the& $s$all& ta-e the for# of estr$%ti!e lesions in one or se!eral !erte'ral 'o ies with little or no in!ol!e#ent of the is% spa%e" e!en in the fa%e of a %o#pression fra%t$re( Before s$%h estr$%ti!e %han)es 'e%o#e e!i ent" a CT or ra ioa%ti!e isotope s%an #a& 'e helpf$l in ete%tin) areas of osteo'lasti% a%ti!it& $e to neoplasti% or infla##ator& isease an %hara%teristi% %han)es are also e!i ent on MRI( Infe%tion of the !erte'ral %ol$#n" osteo#&elitis" is $s$all& %a$se '& staph&lo%o%%i an less often '& %olifor# an t$'er%$le 'a%illi( The patient %o#plains of pain in the 'a%-" of s$'a%$te or %hroni% nat$re" whi%h is e+a%er'ate '& #o!e#ent '$t not #ateriall& relie!e '& rest( Motion 'e%o#es li#ite " an there is per%$ssion3in $%e ten erness o!er the spine in the in!ol!e se)#ents an pain with .arrin) of the spine" as o%%$rs when the heels stri-e the floor( Often these patients are afe'rile an o not ha!e a le$-o%&tosis( The er&thro%&te se i#entation rate is ele!ate as a r$le( CT s%annin) an MRI will $s$all& e#onstrate the in!ol!e !erte'ra/e0 an inter!erte'ral is%@the fin in) of a 'rea%he is% spa%e is one of the feat$res that ifferentiates infe%tio$s fro# neoplasti% iseases of the spine( A para!erte'ral #ass is often fo$n " in i%atin) an a's%ess" whi%h #a&" in the %ase of t$'er%$losis" rain spontaneo$sl& at sites ,$ite re#ote fro# the !erte'ral %ol$#n( We ha!e also en%o$ntere a n$#'er of patients with s$'a%$te 'a%terial en o%ar itis who %o#plaine of se!ere #i line thora%i% an l$#'ar 'a%- pain '$t ha no e!i ent infe%tion of the spine( Spe%ial #ention sho$l 'e #a e of spinal epi $ral a's%ess" whi%h ne%essitates $r)ent s$r)i%al treat#ent( Most often this is $e to staph&lo%o%%al infe%tion" whi%h is %arrie in the 'loo strea# fro# a septi% fo%$s /e()(" f$r$n%le0 or is intro $%e into the epi $ral spa%e fro# an osteo#&eliti% lesion( Another i#portant a!en$e of infe%tion is the intra!eno$s self3a #inistration of a $lterate r$)s an $se of %onta#inate nee les( Rarel& the infe%tion is intro $%e in the %o$rse of a l$#'ar p$n%t$re" epi $ral in.e%tion" or la#ine%to#& for is% e+%ision( In so#e instan%es the so$r%e of the epi $ral infe%tion %annot 'e as%ertaine ( The #ain s&#pto#s are fe!er" le$-o%&tosis" an persistent an se!ere lo%ali=e pain" intensifie '& per%$ssion an press$re o!er the !erte'ral spines6 a itionall& the pain #a& a%,$ire a ra i%$lar ra iation( These s&#pto#s #an ate i##e iate in!esti)ation '& MRI or CT3#&elo)raph& an s$r)i%al inter!ention" prefera'l& 'efore the si)ns of paraple)ia" sphin%ter &sf$n%tion" an sensor& loss 'e%o#e #anifest( E+%eptionall& s#all a's%esses %an 'e treate s$%%essf$ll& with anti'ioti%s alone( A noninfla##ator& for# of a%$te epi $ral %o#pression #a& 'e $e to he#orrha)e /anti%oa)$lant therap&" !as%$lar #alfor#ation0 an " in the %er!i%al re)ion" to rhe$#atoi arthritis /see f$rther on0( Intraspinal He#orrha)e S$ en" e+%r$%iatin) #i line 'a%- pain /le %o$p e poi)nar or >the stri-e of the a))er?0@often with rapi l& e!ol!in) paraparesis" $rinar& retention" an n$#'ness of the le)s@#a& anno$n%e the o%%$rren%e of

s$'ara%hnoi " s$' $ral" or epi $ral 'lee in)( The %o##onest %a$se of s$%h an e!ent is a spinal arterio!eno$s #alfor#ation /AKM0" as is%$sse on pa)e 2G2D( Spinal arterial ane$r&s#s are #$%h less %o##on( It sho$l 'e #entione that 'a%pain of %o#para'le intensit& #a& #ar- the onset of a%$te #&elitis" spinal %or infar%tion" %o#pression fra%t$re" an o%%asionall& :$illain3BarrM s&n ro#e( Pain fro# Kis%eral Disease Pepti% $l%er isease an %ar%ino#a of the sto#a%h #ost t&pi%all& in $%e pain in the epi)astri$#( Howe!er" if the posterior sto#a%h wall is in!ol!e " parti%$larl& if there is retroperitoneal e+tension" the pain #a& 'e felt in the thora%i% spine" %entrall& or to one si e" or in 'oth lo%ations( If intense" it #a& see# to en%ir%le the 'o &( The 'a%- pain ten s to refle%t the %hara%teristi%s of the pain fro# the affe%te or)an6 e()(" if $e to pepti% $l%eration" it appears a'o$t 4 h after a #eal an is relie!e '& foo an anta%i s( Diseases of the pan%reas are apt to %a$se pain in the 'a%-" 'ein) #ore to the ri)ht of the spine if the hea of the pan%reas is in!ol!e an to the left if the 'o & an tail are i#pli%ate ( Retroperitoneal neoplas#s@e()(" l&#pho#as" h&pernephro#as" sar%o#as" an %ar%ino#as@#a& e!o-e pain in the thora%i% or l$#'ar spine with a ten en%& to ra iate to the lower part of the a' o#en" )roins" anterior thi)hs" or flan-( A t$#or in the iliopsoas re)ion often pro $%es a $nilateral l$#'ar a%he with ra iation towar the )roin an la'ia or testi%le6 there #a& also 'e si)ns of in!ol!e#ent of the $pper l$#'ar spinal roots( An ane$r&s# of the a' o#inal aorta #a& in $%e pain that is lo%ali=e to an analo)o$s re)ion of the spine( The s$ en appearan%e of l$#'ar pain in a patient re%ei!in) anti%oa)$lants sho$l aro$se s$spi%ion of retroperitoneal 'lee in)( This pain #a& also 'e referre to the )roin( Infla##ator& iseases an neoplas#s of the %olon %a$se pain that #a& 'e felt in the lower a' o#en" the #i l$#'ar re)ion" or 'oth( As with intense pain hi)her in the spine" it #a& ha!e a 'elt3li-e istri'$tion( Pain fro# a lesion in the trans!erse %olon or first part of the es%en in) %olon #a& 'e %entral or left3si e 6 its le!el of referen%e is to the se%on an thir l$#'ar !erte'rae( If the si)#oi %olon is i#pli%ate " the pain is lower" in the $pper sa%ral spine an anteriorl& in the s$prap$'i% re)ion or left lower ,$a rant of the a' o#en( Retroperitoneal appen i%itis #a& ha!e an o referral of pain to the low flan- an 'a%-( :&ne%olo)i% isor ers often #anifest the#sel!es '& 'a%- pain" '$t their ia)nosis is sel o# iffi%$lt( Thoro$)h a' o#inal palpation as well as !a)inal an re%tal e+a#ination" s$pple#ente '& $ltraso$n an CT s%annin) or MRI" $s$all& is%loses the so$r%e of pain( The $terosa%ral li)a#ents are the #ost i#portant pel!i% so$r%e of %hroni% 'a%- pain( En o#etriosis or %ar%ino#a of the $ter$s /'o & or %er!i+0 #a& in!a e these str$%t$res" %a$sin) pain that is lo%ali=e to the sa%r$# either %entrall& or #ore to one si e( In en o#etriosis" the pain 'e)ins pre#enstr$all& an often #er)es with #enstr$al pain" whi%h also #a& 'e felt in the sa%ral re)ion( Rarel&" %&%li% en)or)e#ent of e%topi% en o#etrial tiss$e #a& )i!e rise to s%iati%a an other ra i%$lar pain( Malposition of the $ter$s /retro!ersion" $ter$s es%ens$s" an

prolapse0 %hara%teristi%all& )i!es rise to sa%ral pain" espe%iall& after the patient has 'een stan in) for se!eral ho$rs( Chan)es in post$re #a& also e!o-e pain here when a fi'ro#a of the $ter$s p$lls on the $terosa%ral li)a#ents( Low3'a%- pain with ra iation into one or 'oth thi)hs is a %o##on pheno#enon $rin) the last wee-s of pre)nan%&( Pain $e to %ar%ino#ato$s infiltration of pel!i% ner!e ple+$ses is %ontin$o$s an 'e%o#es pro)ressi!el& #ore se!ere6 it ten s to 'e #ore intense at ni)ht an #a& ha!e a '$rnin) ,$alit&( The pri#ar& lesion %an 'e in%onspi%$o$s an #a& 'e o!erloo-e on pel!i% e+a#ination( Co%%& &nia This is the na#e applie to pain that is lo%ali=e to the >tail pie%e"? the three or fo$r s#all !esti)ial 'ones at the lower#ost part of the sa%r$#( The tra$#a of %hil 'irth" a fall on the '$tto%-s" a!as%$lar ne%rosis" a )lo#$s t$#or" or one of a !ariet& of other rare t$#ors an anal isor ers %an so#eti#es 'e esta'lishe as the %a$se of pain in this re)ion( 1ar #ore often" the so$r%e re#ains o's%$re( In the past" patients in this latter )ro$p were in is%ri#inatel& s$'.e%te to %o%%&)e%to#&" '$t #ore re%ent st$ ies ha!e e#onstrate that #ost %ases respon fa!ora'l& to in.e%tions of lo%al anestheti% an #eth&lpre nisolone or to #anip$lation of the %o%%&+ $n er anesthesia /Wra& et al0( O's%$re T&pes of Low3Ba%- Pain an the N$estion of Ps&%hiatri% Disease It is a safe %lini%al r$le that all patients who %o#plain of low3'a%- pain ha!e so#e t&pe of pri#ar& or se%on ar& isease of the spine an its s$pportin) str$%t$res or of the a' o#inal or pel!i% !is%era( Howe!er" e!en after %aref$l e+a#ination" there re#ains a si=a'le )ro$p of patients in who# no patholo)i% 'asis %an 'e fo$n for the 'a%- pain( Two %ate)ories %an 'e re%o)ni=e ; one with post$ral 'a%- pain an another with a))ra!atin) ps&%hiatri% illness" '$t there are alwa&s %ases where the ia)nosis re#ains o's%$re( Post$ral Ba%- Pain Man& slen er" astheni% in i!i $als an so#e fat" #i le3a)e ones ha!e %hroni% is%o#fort in the 'a%-" an the pain interferes with effe%ti!e wor-( The ph&si%al e+a#ination is $nre!ealin) e+%ept for sla%- #$s%$lat$re an poor post$re( The pain is iff$se in the #i le or lower re)ion of the 'a%-6 %hara%teristi%all&" it is relie!e '& 'e rest an in $%e '& the #aintenan%e of a parti%$lar post$re o!er a perio of ti#e( Spinal #anip$lation is sai to ha!e helpe a n$#'er of these patients( Pain in the ne%- an 'etween the sho$l er 'la es is a %o##on %o#plaint a#on) thin" tense" a%ti!e wo#en an see#s to 'e relate to ta$t trape=i$s #$s%les( A oles%ent )irls an 'o&s are s$'.e%t to an o's%$re for# of epiph&seal isease of the spinal !erte'rae /S%he$er#ann isease0" whi%h" o!er a perio of 4 to G &ears" #a& %a$se low3'a%- pain $pon e+er%ise( Ps&%hiatri% Illness Low3'a%- pain #a& 'e a #a.or s&#pto# in patients with h&steria" #alin)erin)" an+iet& ne$rosis" epression" an h&po%hon riasis as well as in #an&

ner!o$s persons whose s&#pto#s o not %onfor# to an& of these ps&%hiatri% illnesses( A)ain" it is )oo pra%ti%e to ass$#e that pain in the 'a%- in s$%h patients #a& si)nif& isease of the spine or a .a%ent str$%t$res" an this sho$l alwa&s 'e %aref$ll& so$)ht( Howe!er" e!en when so#e or)ani% fa%tors are fo$n " the pain #a& 'e e+a))erate " prolon)e " or wo!en into a pattern of in!ali is# 'e%a$se of %oe+istent pri#ar& or se%on ar& ps&%holo)i% fa%tors( This is espe%iall& tr$e when there is the possi'ilit& of se%on ar& )ain /nota'l& wor-ers* %o#pensation or settle#ent of personal in.$r& %lai#s0( Patients see-in) %o#pensation for protra%te low3'a%- pain witho$t o'!io$s str$%t$ral isease ten " after a ti#e" to 'e%o#e s$spi%io$s" $n%ooperati!e" an hostile towar their ph&si%ians or an&one who #i)ht ,$estion the a$thenti%it& of their illness( One notes in the# a ten en%& to es%ri'e their pain !a)$el& an a preferen%e to is%$ss the e)ree of their isa'ilit& an their #istreat#ent at the han s of the #e i%al profession( The es%ription of the pain #a& !ar& %onsi era'l& fro# one e+a#ination to another( Often also" the re)ion/s0 in whi%h pain is e+perien%e an its ra iation are nonph&siolo)i%" an the %on ition fails to respon to rest an ina%ti!it&( These feat$res an a ne)ati!e e+a#ination of the 'a%- sho$l lea one to s$spe%t a ps&%holo)i% fa%tor( A few patients" $s$all& fran- #alin)erers" a opt the #ost 'i=arre )aits an attit$ es" s$%h as wal-in) with the tr$n- fle+e at al#ost a ri)ht an)le /%a#pto%or#ia0" an are $na'le to strai)hten $p( Or the patient #a& 'e $na'le to 'en forwar e!en a few e)rees" espite the a'sen%e of #$s%le spas#" an #a& win%e at the sli)htest press$re" e!en o!er the sa%r$#" whi%h is sel o# a site of ten erness $nless there is pel!i% isease( The epresse an an+io$s patient with 'a%- pain represents a tro$'leso#e pro'le#( A %o##on error is to #ini#i=e the i#portan%e of an+iet& an epression or to as%ri'e the# to worr& o!er the illness an its so%ial effe%ts( In these %ir%$#stan%es" %o##on an #inor 'a%- ail#ents" e()(" those $e to osteoarthritis an post$ral a%he" et%(" are enhan%e an ren ere intolera'le( S$%h patients are often s$'.e%te to $nne%essar& s$r)i%al pro%e $res( The isa'ilit& see#s e+%essi!e for the e)ree of spinal #alf$n%tion" an #iser&" irrita'ilit&" an espair are the pre!ailin) feat$res of the s&n ro#e( One of the #ost relia'le ia)nosti% feat$res is the response to r$)s or other #eas$res that alle!iate the epression /see Chap( B70( 1aile Ba%- S&n ro#e S$rel& the #ost iffi%$lt patients to #ana)e are those with %hroni% low3'a%- pain who ha!e alrea & ha one or #ore la#ine%to#ies an so#eti#es a f$sion witho$t s$'stantial relief( In one lar)e series of patients operate on for pro!en is% prolapse" 4B per%ent were left with tro$'leso#e s&#pto#s an 28 per%ent re,$ire f$rther s$r)er& /Weir an 9a%o's0( In s$%h patients o$r pra%ti%e has 'een to repeat the MRI an CT3#&elo)raph&( In a s#all n$#'er of the patients" it will 'e fo$n that the is% has rer$pt$re " or that there is a lateral re%ess stenosis" or that a is% has r$pt$re at another le!el( It #a& happen that the s$r)eon i not re#o!e all the

is% tiss$e" in whi%h %ase another operation to re#o!e the re#ain er will 'e s$%%essf$l( Ele%tro#&o)raph& an ner!e %on $%tion st$ ies" sear%hin) for e!i en%e of a ra i%$lopath&" are helpf$l( If there is e!i en%e of a ra i%$lopath& '$t no is% #aterial" or onl& s%ar tiss$e is seen" one oes not -now whether the pain is $e to in.$r& fro# the initial r$pt$re or was the after#ath of s$r)er&( Kario$s e+planations are then in!o-e @ra i%$litis" lateral re%ess s&n ro#e" fa%et s&n ro#e" $nsta'le spine" an l$#'ar ara%hnoi itis es%ri'e earlier in the %hapter /see re!iews '& N$iles et al an '& Lon) as well as the >S&#posi$#? liste in the Referen%es0( One wo$l s$ppose that these %hroni% pain %ases %o$l 'e s$' i!i e into a )ro$p with %ontin$e ra i%$lar pain an another with referre pain fro# isease of the spine( Howe!er" on%e the pain 'e%o#es %hroni%" the separation is not eas&( Press$re o!er the spine" '$tto%-" or thi)h #a& %a$se pain to 'e pro.e%te into the le)( Li o%aine 'lo%-s of ner!e roots ha!e &iel e in%onsistent res$lts( O%%$pational in.$ries" in whi%h wor-ers* %o#pensation or liti)ation is a fa%tor" #a-e the patient*s report of therape$ti% effe%ts al#ost worthless( Trans%$taneo$s sti#$lators" posterior %ol$#n sti#$lators" intrathe%al in.e%tions of anal)esi%s" an epi $ral steroi in.e%tions ha!e sel o# helpe for lon) in o$r e+perien%e( At present the 'est that %an 'e offere the patient is wei)ht re $%tion /if he is o'ese0" stret%hin) an pro)ressi!e e+er%ise to stren)then a' o#inal an 'a%- #$s%les" as well as nonsteroi al anti3infla##ator& an anti epressant r$)s( A trial of #assa)e therap& or a li#ite %o$rse of spinal #anip$lation is reasona'le( Pre!enti!e Aspe%ts of Lower Ba%- Pain Witho$t o$'t these are i#portant( There wo$l 'e #an& fewer 'a%- pro'le#s if a $lts -ept their tr$n- #$s%les in opti#al %on ition '& re)$lar slow stret%hin) an e+er%ise s$%h as swi##in)" wal-in) 'ris-l&" r$nnin)" an %alistheni% pro)ra#s of the Cana ian Air 1or%e t&pe( Mornin) is the i eal ti#e for e+er%isin)" sin%e the 'a%of the ol er a $lt ten s to 'e stiffest followin) a ni)ht of ina%ti!it&( This happens re)ar less of whether a 'e 'oar or stiff #attress is $se ( Sleepin) with the 'a%h&pere+ten e an sittin) for lon) perio s in an o!erst$ffe %hair or a 'a l& esi)ne %ar seat are parti%$larl& li-el& to a))ra!ate 'a%-a%he( It is esti#ate that intra is%al press$res are in%rease 488 per%ent '& %han)in) fro# a re%$#'ent to a stan in) position an A88 per%ent when sl$#pe in an eas& %hair( Corre%t sittin) post$re lessens this press$re( Lon) trips in a %ar or plane witho$t %han)e in position p$t #a+i#al strain on is%al an li)a#ento$s str$%t$res in the spine( Liftin) fro# a position in whi%h the 'a%- is fle+e " as in re#o!in) a hea!& s$it%ase fro# the tr$nof a %ar" is ris-& /alwa&s lift with the o'.e%t %lose to the 'o &0( Also" s$ en stren$o$s a%ti!it& witho$t %on itionin) an war#$p is li-el& to in.$re is%s an their li)a#ento$s en!elopes( Certain fa#ilies see# ispose to in.$r& of these str$%t$res(