Common abnormal findings

• Restriction of spinal movement.

• Pain exacerbated by movement of the spine.

• Neurological signs associated with acute nerve root compression.

CASE HISTORY

A young man of 25 experienced intermittent lumbar backache after playing squash. After one of these episodes he developed acute lumbar backache while putting on his socks. The pain was extremely severe; he had difficulty moving and he had to crawl to the toilet. After 48 hours the pain spread into the posterolateral aspect ol his right leg and across the dorsum oi his foot and into his big toe. He had associated paraesthesla in this distribution. Coughing acutely exacerbated his discomfort. There was no systemic upset.

He could only get out of bed with assistance and stand with extreme difficulty. There was flattening of his lumbar lordosis. His pain was increased on attempted forward flexion and right lateral flexion of the spine. Straight leg raising on the right was reduced to 30 degrees. There was weakness of dorsiflexlon of the big toe and depression of sensation across the dorsum of the foot and into the first interdigltal cleft. The ankle jerk was intact. Rectal examination was normal. The history mads infection or tumour unlikely and was highly suggestive of an acute prolapsed Intervertebral disc. MRI scan confirmed the diagnosis.

Learning points

• The distribution of pain and the associated neurological signs indicate the level of the lesion (L4/5 disc).

• Abnormal sphincter tone and loss ol perianal sensation suggest cauda equina compression which demands operative intervention.

The history and examination of the limb joints aims to distinguish between systemic conditions, which may cause pathology at several sites (e.g. rheumatoid arthritis), local conditions in which a single sile is involved (e.g. tennis elbow) and conditions where limb symptoms are due to referred pain from disease of the spine or nerve roots. The distinction between inflammatory and non-inflammatory conditions is also made on the basis of the pattern of diurnal stiffness and pain, relation to activity and the presence of extra-articular features. It is also important to remember that pain arising in a joint may be referred and difficult for the patient to localise (Tabic 8.8).

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