Assessment

HISTORY. Establish a history of back pain, including a description of the location and intensity of the pain. Often, the symptoms are of a gradually progressing nature over a period of days to weeks. The development and distribution of extremity pain help determine the level of the involved disk. Ask about weakness in the extremities, altered sensation, or muscle spasms; ask if pain intensifies during Valsalva's maneuver, coughing, sneezing, or bending. Establish a history of sensory and motor loss in the area that has been innervated by the compressed spinal nerve root.

PHYSICAL EXAMINATION. Document any gait abnormalities, such as a limp. Test the patient's deep tendon reflexes in the upper and lower extremities. Perform a sensory evaluation of the patient's sharp-dull and fine touch discrimination. Motor strength testing of the involved extremities is also important, again to determine the extent of injury to the spinal cord or nerve roots. Perform range-of-motion studies of either the cervical, the thoracic, or the lumbar regions. Conduct stretch tests for nerve root irritation, including the straight leg raise test; if the sciatic nerve is irritated, there will be pain in the involved leg. The Braggart's test, passive stretching of the foot in dorsiflexion, is positive if it elicits pain along the sciatic nerve distribution. The "bow string" sign is performed with the patient sitting and the knees flexed just beyond a 90-degree angle, the body bent slightly forward to increase the stretch on the sciatic nerve. A positive response occurs when gentle pressure with the examiner's finger into the popliteal space further stretches the sciatic nerve, producing more pain. Check the patient's peripheral vascular status, including peripheral pulses and skin temperatures, to rule out ischemic disease, another possible cause of leg pain and numbness.

PSYCHOSOCIAL. The individual may be unexpectedly debilitated. The assessment should include an evaluation of the patient's ability to deal with unexpected changes in lifestyle, roles, and income. Along with severe pain, an employed person may be facing a prolonged period of disability and reduced income.

Diagnostic Highlights

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