A 32-year-old unemployed man presented with complaints of severe pain in the lower back that radiated into the right buttock, posterior thigh, calf, and lateral foot and two toes. The pain in the back started about 2 weeks ago after sitting for a period of a few hours and initially was relieved by rest. Over the next few days, the pain gradually got worse. The patient reported the pain to be aggravated with bending at the waist and sitting, and lessened with right side lying with the hips and knees flexed. Difficulty with assuming an erect posture after lying down or sitting also was reported. The patient reported not being able to play with or carry his 2-year-old son. Further questioning revealed that the patient had a history of minor back pain but was otherwise in good health and had no reports of bowel or bladder impairment.
What is your best working hypothesis at this stage?
The best working hypothesis at this stage would be a neurogenic compromise with a nontraumatic onset. The distribution of symptoms would tend to indicate involvement of the L5-S1 level.
Does this presentation/history warrant a Cyriax lower quarter screening examination?
This patient certainly warrants a lower quarter screening examination -- prompted by the reports of a relatively insidious onset of symptoms and the report of lower extremity symptoms.
The physical examination revealed the following findings:
- The patient was a slightly obese man who had preferred to stand in the waiting room. His standing posture revealed a flexed hip and knee on the right side when weight bearing, with moderate kyphosis and a rotoscoliosis with right convexity of the lumbar spine, and shoulder girdle retraction.
- The patient demonstrated a marked restriction of gait and lumbar motion.
- Active range of lumbar motion revealed a significant restriction of trunk flexion at about 35 degrees from the kyphotic start position, which reproduced the posterior leg pain. The patient attempted to compensate during trunk flexion by bending at the hips and knees.
- The patient was unable to perform lumbar extension or right side bending because of a sharp increase in the radiation of pain into the right buttock and posterior thigh.
- Left side bending of the lumbar spine was limited by 25 percent, producing a slight ache in the right side of the low back.
- The right straight leg raising (SLR) reproduced the radiating pain into the posterior right leg, and a hamstring spasm at 15 degrees. The application of passive ankle dorsiflexion increased the patient’s symptoms. The left SLR was limited by spasm at 60 degrees, producing right low back, right buttock, and posterior thigh pain. The addition of neck flexion or dorsiflexion to the left SLR had no effect on the symptoms. The slump test was deferred as it was felt that ...