Page 103 Guide to Pain Management in Low-Resource Settings

Physical Examination: Orthopedics 91

are intact (there is a refl ex associated with the L5 root, Computerized axial tomography imaging is of value in
but it is diffi cult to evaluate). assessing spinal fractures and dislocations.
Usually—although there are exceptions—the L5
How to examine the spine
root is compressed by an abnormal L4–5 disk and the
S1 root by an abnormal L5–S1 dis,. Th is relationship • Look for systemic fi ndings such as fever, chills,
can be seen anatomically. weight loss.
• Observe as the patient enters the room: look for
What is the cause of the slapping foot? gait abnormalities, response to your greeting, and
• Gait incoordination secondary to pain? general state of well-being.
• Weakness of the muscles in the anterior compart- • Evaluate alignment and symmetry from the front,
ment of the leg? back, and side. Check for scoliosis by observing
• Compression of the common fi bular nerve at the thoracic symmetry with the patient bending for-
knee? ward and for kyphosis by a break in the smooth
• Weakness of ankle plantar fl exor muscles? spinal curve in the side view.
• Peroneal muscle weakness? • Palpate landmarks: sacroiliac joints, spinous pro-
cesses, paravertebral muscles, sacrum.
How to reach a diagnosis • Check the range of motion with forward fl exion,
Th is is a common symptom and a signifi cant problem extension, lateral bending & rotation.
for the patients because the weakness of ankle extension • Elicit deep tendon refl exes at the knee and ankle.
tends to make them trip over curbs and carpet edges • Perform the straight leg raising test: with the
and makes an embarrassing noise walking on tile fl oors. patient supine elevate one leg at a time with the
As mentioned above, it can result from injury to the L5 knee straight. Pain felt in the calf is a positive test
root as in this patient, from a tight anterior compart- indicating tension on the involved nerve.
ment (as in case 3), or from compression of the pero- In general, mechanical back pain will show only
neal nerve. Th e most common location for such com- a loss of normal spinal motion. Disk disease with nerve
pression is at the fi bula neck, and it may result from a root involvement will present with the above signs plus
tight cast or splint or positioning on the operating ta- sensory, motor, or refl ex changes and a positive straight
ble—look at this area on your dissection. leg raising test, as in Case 2. Tuberculous infection pres-
ents with systemic signs, spinal deformity, usually ky-
Sequentially, the nerves most likely to be phosis, and may have neurological changes. Th e neu-
involved are:
rological involvement from tuberculosis involves the
• L4 root: femoral nerve: posterior tibial nerve spinal cord, rather than nerve roots, and the physical
• L5 root: sciatic nerve: posterior tibial nerve fi ndings may include hyperactive refl exes, clonus, and
• S1 root: sciatic nerve: common peroneal nerve spasticity. Spinal tumors often cause the same neuro-
• L5 root: sciatic nerve: common peroneal nerve logical abnormalities. Adolescent patients may present
with either an isolated kyphosis or scoliosis. Th ese are
How to examine the back
usually of unknown cause, idiopathic, and while they
Back pain is a universal problem, which must be ad- may progress, they do not cause severe pain; just some
dressed carefully in order to separate musculoligamen- mild discomfort. If the pain is signifi cant, other causes
tous mechanical back discomfort from other signifi cant such as tumor or infection should be considered.
problems for which more aggressive treatment is need-
ed, such as infection, fractures, tumors, or neurologic
Pearls of wisdom
involvement from disc disease as the case illustrates.
Fortunately the initial assessment can be done simply
• Th ere are a few particular problems involving
and still provide a great deal of information. musculoskeletal pain for which a physical ex-
Radiographic assessment is helpful in evaluating
amination is helpful. Chronic or recurrent back
deformity or destruction of bone. Magnetic resonance pain is especially diffi cult to treat unless a clear
imaging is useful in evaluating soft-tissue problems
diagnosis such as tuberculosis, pyogenic infec-
such as tumor, infection, and nerve root impingement. tion, tumor, or disk disease is established.