NEUROLOGY IN PRACTICE

Neurologic Approach to Diagnosis of Low ac! Pain

"a#es R$ Lehrich% &D Harvard Medical School 'e( wor)s* back pain, pain, lumbar spine, lumbar disks

Intro)uction
Low back pain is extremely common and has major economic significance in industrial societies. It is reported to occur in 26% of the working population each year and occurs to a disabling degree in 2 to %. !ighty percent of the population ha"e at least one episode of low back pain in their lifetimes. It is the fifth leading reason for medical office "isits in the #nited $tates. Low%back injury compensation accounts for &&% of all workers' compensation costs ()*& for medical treatment, 2*& for indemnity+. $e"enty%fi"e percent of compensation payments go to back patients, although they constitute only &% of total compensation patients (,lein et al, )- ./ 0art et al, )--1+. Low back pain occurs most fre2uently between the ages of twenty and forty and is more se"ere in older patients. 3here is no strong association based on sex, height, body weight, or physical fitness. 0igh%risk occupations include miscellaneous labor, garbage collection, warehouse work, and nursing, all of which are usually associated with lifting, twisting, bending, and reaching. Prognosis 3he typical attack in"ol"es &1 days (median+ of pain and - to 2) days out of work. 3hose who are out of work longer than 6 months ha"e only a 14% likelihood of returning. 3his drops to 21% after more than ) year out and to nil after 2 years. 5fter an initial episode, the probability of recurrence is increased fourfold. 3reatment tends to be less successful in workers' compensation cases. 3he a"erage cost for care is ..1 times greater if the patient is represented by an attorney.

Classification
Low back pain is an important part of neurologic and general medical practice. 6f all office "isits for back pain, 16% are to family practitioners and internists, 21% are to orthopedic surgeons, 7% are to neurosurgeons, and .% are to neurologists. 3hese patients make up )4% of the a"erage neurologist's caseload (0art et al, )--1+. 3he neurologist is usually called upon to e"aluate and treat the patient with acute or subacute pain and symptoms and signs of ner"e%root irritationradiating pain, weakness, numbness, and bladder or bowel symptoms. $uch patients make up a small minority of those with low back pain. In many of these cases, the neurologist is also asked to assess the presence and degree of impairment (physical defect+ and disability (what the patient can or can't do as a result of this defect+ (585, )--&+.

3here are a multitude of causes of low back pain. !"en when there is e"idence of ner"e%root in"ol"ement (radiculopathy+, not e"ery patient has a herniated lumbar disc. 3he classifications outlined in 3able ) may be helpful in the differential diagnosis.

Clinical E+aluation
5s for any neurologic patient, the general physical and neurologic examinations and history are essential. 3his discussion will emphasi9e areas of special concern in the e"aluation of back pain. History :articular note should be made of any preceding trauma, prior attacks of pain, prior e"aluations, prior or current treatment, and the duration and progression of symptoms. 3he patient should be asked about weakness/ numbness/ dysesthesias and paresthesias/ bladder, bowel, and sexual dysfunction/ and any accompanying abdominal or flank pain. Pain In2uire as to the 2uality, location, and radiation of pain, and any exacerbating or relie"ing factors and acti"ities. $e"ere, constant back pain persisting at night suggests the presence of neoplasm, infection, or lateral recess ner"e%root compression. :ain fibers are present in the annulus surrounding the disc (in the spinal ligaments, facets, and joint capsules+ but not in the inter"ertebral disc itself. ;er"e%root pain is usually brief, sharp, and shooting, is often increased by coughing, straining, standing, or sitting, and is usually relie"ed by lying down. :eripheral%ner"e or plexus pain is usually described as burning, tingling (pins and needles+, or <asleep< or numb in 2uality/ it is usually worse when the patient is lying down at night. ($ee 3able 2.+ In painful radiculopathies and mononeuropathies, the area of pain and sensory abnormality may extend beyond the known sensory distribution of the affected peripheral ner"e or beyond the dermatome of the affected%root or dorsal%root ganglion, as in postherpetic neuralgia. 3his phenomenon has been attributed to central ner"ous system plasticity. In most ner"e%root syndromes, howe"er, a precise description of radiating pain will help locali9e to a ner"e%root le"el. Physical Examination 3he general physical examination can be as important as the neurologic examination and should include the "asculature (especially the pedal pulses+, abdomen, inguinal areas, and rectum (especially if a cauda e2uina syndrome is suspected+. 3he patient should be undressed. =atch how the patient mo"es, sits, and stands. Look for atrophy (measure the calf and thigh circumferences for asymmetry+, fasciculations, pel"ic tilt (<bad< side is down+, in"oluntary knee flexion (to guard against root traction+, scoliosis, and cafe au lait spots (they might indicate neurofibromatosis+. >ait testing should include walking on heels and on toes. :alpate the lower spine, paraspinal muscles, sciatic notches, and sciatic ner"e looking for tenderness, muscle spasms, and radiating pain. 8uscle tenderness may be associated with

ner"e%root irritation (calf muscles with $), anterior tibial muscles with L1, and 2uadriceps with L.+.
Ner+e Root ,tretching

?oots may be impinged upon or tethered by herniated discs or other lesions, so that stretching the root causes pain. 3his should be tested by ha"ing the patient bend forward or by straight% leg raising ($L?+. $L? is performed by raising the extended leg of a supine patient to determine whether this action elicits pain in the leg, buttock, or back, and, if so, at what angle from the hori9ontal the pain occurs. 3he pain is usually worsened by dorsiflexion at the ankle and relie"ed by flexion of the knee and hip. :ositi"e $L? results usually indicate $) or L1 root irritation. :ain occuring in the contralateral, symptomatic leg when the asymptomatic leg is raised is considered a positi"e crossed $L? test, which usually indicates the presence of a disc herniation medial to the ner"e root, often with an extruded disc fragment. ?e"erse $L? tests detect L& or L. root irritation. 3he patient lies prone or on his side, and the thigh is extended at the hip joint. If the patient has hip or groin pain, the examiner should rotate the hip/ pain on hip rotation suggests hip disease rather than radiculopathy.
&otor E-a#ination

It is helpful to bear in mind certain features of the motor examination of the lower extremities in patients with low back pain. $ince it is difficult to detect proximal leg weakness when the patient is lying down, it may be necessary to ask her to attempt to rise from a s2uatting position. $imilarly, gastrocnemius weakness is easiest to detect with repeated rising up on the toes. 3oe flexors and extensors usually become weak before the foot muscles do. If the gluteus maximus (supplied by $)+ is weak, one buttock may sag/ gluteus medius (L1+ weakness may cause a lurching or waddling (3rendelenburg+ gait. In a patient with root pain, do not test the dorsiflexors of the foot with the knee extended, since this may stretch the $) or L1 root and increase sciatic pain. @or the same reason, 2uadriceps strength should be tested with the patient prone. 8uscles are inner"ated by more than one ner"e root, so total paralysis implies a lesion of multiple roots or of peripheral ner"es. !"en if a single root has been se"ered, there is little weakness. 5trophy is rarely seen unless symptoms ha"e been present for more than three weeks. $e"ere atrophy should raise the suspicion of an extradural neoplasm.
,ensor( E-a#ination

5 dermatomal distribution of loss of pinprick and touch sensation indicates and locali9es root in"ol"ement

(@igure )+. Aermatomal and peripheral ner"e sensory distributions (from ,eegan, BB, >arrett, @A. 5nat. ?ec. )42C.)), )-. / and 0aymaker, =, =oodhall, D. :eripheral ;er"e Injuries. 2d ed. :hiladelphia. $aunders. )-1&+. Decause there is a wide o"erlap of root distributions, a single root lesion usually causes mild hypalgesia. 3he examiner may not be able to detect any sensory deficit, e"en though the patient has sensory symptoms.
Ten)on refle-es

5symmetry of the ankle and knee jerks can be helpful in identifying the affected ner"e root. Nerve-Root Syndromes In $) ner"e%root syndromes (see 3able &+, leg pain is often worse than low back pain. :ain and paresthesias are felt in the buttock, posterior thigh, posterolateral calf and heel, and sometimes in the lateral foot and last two toes. ;umbness and pinprick hypalgesia may be in the fifth toe and lateral foot, and, to a lesser degree, in the posterolateral calf and posterolateral thigh. 3here may be weakness of the toe flexors, the gastrocnemius, and (rarely+ the hamstrings as well as toe adbuction and e"ersion of the foot. 3he ankle jerk is often diminished or absent. In L1 ner"e%root syndrome, low back pain is often worse than leg pain. :ain and paresthesias radiate to the posterolateral thigh, groin, lateral calf, dorsomedial foot, and first two toes. ;umbness and hypalgesia may be found in the great toe and medial foot, and, to a lesser extent, the anterolateral calf. =eakness may be noted in the extensor hallucis longus (!0L+, the tibialis anterior (35+, and peroneal muscles, causing a foot drop. 3here is usually no reflex loss. In L. and L& ner"e%root syndromes, low back pain is worse than leg pain. 3here may be some anterior thigh pain. ;umbness and hypalgesia may be present o"er the anteromedial thigh and knee. =eakness may be detected in the 2uadriceps and iliopsoas muscles. 3he knee jerk is often diminished or absent. Inconsistencies

$ince some patients with back pain may exaggerate their symptoms, especially in medicolegal or workers' compensation cases, it is important to detect inconsistencies in the clinical presentation (8acnab and 8cEullock, )--4/ =addell et al, )- 4+. 3he history may indicate that the patient is able to engage in acti"ities inconsistent with the se"erity of his complaints. $ymptoms may be described in an exaggerated or histrionic manner. Auring the examination, tenderness may be elicited by minimal pressure or o"er areas where pain would not be expected. 5xial loading, by pressing down on top of the head, or rotating the body at the hips or shoulders should not elicit low back pain. It may be helpful to distract the patient, to see whether there is more mobility in spontaneous acti"ities than elicited during the formal examination. 3he patient may be obser"ed during dressing (especially shoes and socks+ and getting on and off the examination table. $traight%leg raising ($L?+ should be tested when she is in a sitting position (e.g., while testing the plantar responses or measuring the calf circumferences+ as well as when supine. 3here should be no significant difference in the degree of hip flexion with sitting or supine $L? or when the patient bends forward while standing. ;ondermatomal or otherwise nonanatomic distributions of sensory loss should also be noted. In the motor examination, sudden gi"ing way, jerky mo"ements, or weakness appearing to in"ol"e many muscle groups should raise suspicion. ;ote whether the patient appears to o"erreact during the examination, including what appears to be a disproportionate "erbali9ation of pain on minimal pro"ocation, dramatic facial expressions, muscle tension and tremors, collapsing when asked to bear weight, and re2uiring a companion for dressing and undressing. 3hese obser"ations must be considered in the context of the o"erall examination. $e"ere pain can cause extreme reactions in some patients.

La.orator( E+aluation
Laboratory tests are not necessary in e"ery patient. 3hey are important to "erify the diagnosis if surgery is contemplated and are sometimes necessary to clarify the differential diagnosis. $ince F rays, E3 and 8?I scans, myelograms, and other tests may be abnormal in asymptomatic patients, the results must be interpreted with the entire clinical presentation in mind. $ome guidelines are outlined in 3able .. (@or a detailed discussion, see <Laboratory !"aluation of Low Dack :ain< in this issue.+

&anage#ent
8ost patients with back pain will respond to conser"ati"e treatment. >uidelines appropriate to the primary care physician as well as to the neurologist are outlined in 3able1 . (@or a more detailed discussion, see <8anagement of Low Dack :ain< in this issue.+

References
,lein D:, Bensen ?E, $anderson L8C 5ssessment of workers'compensation claims for back strains*sprains. B 6ccup 8ed 26C..&, )- .. 0art L>, Aeyo ?5, Eherkin AEC :hysician office "isits for low back pain. @re2uency, clinical e"aluation, and treatment patterns from a #$ ;ational $ur"ey. $pine 24C)), )--1. 5merican 8edical 5ssociation. >uides to the e"aluation of permanent impairment, .th ed. EhicagoC 585, )--&. 8acnab I, 8cEullock BC Dackache, 2nd ed. DaltimoreC =illiams and =ilkins, )--4.

=addell >, 8cEulloch B5, ,umel !>, et alC ;onorganic signs in low back pain. $pine 1C))7, )- 4. 8iller >8, @orbes >$, 6nofrio D8. 8agnetic resonance imaging of the spine. 8ayo Elin :roc 6.C- 6, )- -. Cop(right / 0112 &assachusetts Institute of Technolog(