Special Diagnostic Considerations

Special Diagnostic Considerations

Disc Pain Distribution

               Theannulus fibrosis has nociceptive nerve endings in it, and therefore an annular tear can cause pain referral of purely discogenic origin into the low back, buttock, and sacroiliac region, and lower extremity even in the absence of neural compression.

Facet Joint Pain Distribution

               The zygapophysial joints are well innervated, and facet naturopathy can cause lowback pain and referred pain into the buttocks and lower extremities. Classic facet syndrome pain is in the hip and buttock, with cramping leg pain primarily above the knee, low back stiffness (especially in the morning with inactivity), and the absence of paresthesia. Classic signs are local paravertebral tenderness, hyperextension back pain, and no neurologic or root tension signs with hip, buttock, or back pain on straight leg raising.

Differentiating Disc from Facet Pain Distribution

               Differential diagnosis of lower-extremity pain of disc versus facet includes the facet that facet pain rarely extends beyond the calf, usually only into the thigh, and not into the foot. Radicular disc pain is potentially worse than back pain. In facet pain, the back pain is worse than the leg pain. Radicular pain is usually accompanied by neurologic signs in disc legions but not in facet problems.

Elevated Cerebrospinal Fluid Proteins

               The protein concentration in the cerebrospinal fluid (CSF) is often increased in patients with sciatica, probably because of plasma proteins leaking through the blood-nerve root barrier into the cerebrospinal fluid. Significantly higher values of the CSF/ serum albumin ratio and the CSF/ serum immunoglobulin G ratio were found in patients with positive SLR test results and paresis compared with patients with no clinical findings. Elevated CSF proteins seem to be an important indicator of the functional status of the nerve root and a measure of the degree of seriousness of sciatica.

               Nerve root injury, as suggested by a positive straight leg raising test, appears to be neurochemically linked to altered CSF vocative intestinal peptide levels in patients with radicular pain symptoms caused by disc herniation and lumbar stenosis.

Differentiating Recurrent Disc Herniation from Scar Formation

               Gradually increasing symptoms beginning a year or more after discectomy are considered more likely caused by scar formation, whereas a more abrupt onset at any interval after surgery is more likely cause by a recurrent herniated disc.

               Symptoms and signs that best distinguish between recurrent herniation and fibrosis are pain on coughing, a severly reduced walking capacity, and a SLR test positive at less than 30 degrees; the presence of two or more of these parameters was found in 16 of 22 patients with recurrent herniation, compared with 5 of 18 patients with fibrosis.

Pathologic Change in Sciatica Foramen as Cause of Sciatica

               Longstanding sciatica symptoms and signs should include pathologic changed in the sacral foramen by benign and malignant neoplasms as well as infection. CT scanning should include the sciatic foramen in longstanding, undiagnosed sciatica.

Dorsal Root Ganglion Compression Symptoms

               Dorsal room ganglion compression can result in myalgia and tendonitis symptoms into the lower extremities, as well as intermittent claudicating, sciatica, and groin pain.

Clinical Instability Defined

               White and Panjabi states that a narrowed disc space without spondylosis is a sign of instability. Clinical instability is defined as the loss of the spine’s ability, under physiologic loads, to maintain normal relationships between vertebrae so that no damage and no subsequent limitation to the spinal cord or nerve roots occurs and no incapacitating deformity or pain develops from structural change.

Differentiating Contained from Noncontained Disc

               When a disc lesion is present, a differential diagnosis between protrusion and prolapse is necessary. The sudden onset of leg pain and absence of low back pain indicates protrusion.

Sciatic Scoliosis Defines Disc Lesion Type

               Relief of pain on lateral flexion may indicate whether the disc protrusion is lateral or medical to the nerve root.

Cervical Disc as Cause of Myofascitis and Leg Pain

               Cervical disc herniations have been reported to cause Myofascial pain and altered deep reflexes in the lower extremities; the Myofascial pain caused by this irritation ceased once the mechanical cervical disc rubbing of the cord was surgically relieved.

Leg Length Effect on Low Back Pain

               Leg length inequality alters gait efficiency and predisposes to low back pain and hip arthrosis.

What Is the Best Lifting Posture?

Back Muscle Forces in Flexion Similar to Upright Posture

               Compression forces and moments exerted by the back muscles in full flexion are not significantly different from those produced in the upright posture.