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Back pain

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Symptoms of a sciatica may often be difficult to distinguish from those of other spinal disorders or simple back strain


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Clinical evaluation

The most common levels for a sciatica are L4-5 and L5-S1. The onset of symptoms is characterized by a sharp, burning, stabbing pain radiating down the posterior or lateral aspect of the leg, to below the knee. Pain is generally superficial and localized, and is often associated with numbness or tingling. In more advanced cases, motor deficit, diminished reflexes or weakness may occur in siatica.

If a sciatica is responsible for the back pain, the patient can usually recall the time of onset and contributing factors, whereas if the pain is of a gradual onset, other degenerative diseases are more probable than disc herniation.

Rheumatoid arthritis often begins in the appendicular skeleton before progressing to the spine. Inflammatory arthritides, such as ankylosing spondylitis, cause generalized pain and stiffness that are worse in the morning and relieved somewhat throughout the day.


"Red Flags" for Potentially Serious ConditionsPossible condition Findings from the medical historyFracture * Major trauma (motor vehicle accident, fall from height)

* Minor trauma or strenuous lifting in an older or osteoporotic patient Tumor or infection * Age >50 years or <20 years

* History of cancer

* Constitutional symptoms (fever, chills, unexplained weight loss)

* Recent bacterial infection

* Intravenous drug use

* Immunosuppression (corticosteroid use, transplant recipient, HIV infection)

* Pain worse at night or in the supine position Cauda equina syndrome* Saddle anesthesia

* Recent onset of bladder dysfunction

* Severe or progressive neurologic deficit in lower extremity

Cauda equina syndrome. Only the relatively uncommon central disc herniation provokes low back pain and saddle pain in the S1 and S2 distributions. A central herniated disc may also compress nerve roots of the cauda equina, resulting in

Low back strain should be differentiated from central herniated disc. Pain caused by low back strain is exacerbated during standing and twisting motions, whereas pain caused by central disc herniation is

Physical and neurologic examination of the lumbar spine

External manifestations of pain, including an abnormal stance, should be noted. The patient's posture and gait should be examined for sciatic list, which is indicative of disc herniation. The

Range of motion should be evaluated. Pain during lumbar flexion suggests

Motor, sensory and reflex function should be assessed to determine the

continue to next page of location of back pain and nerve root See the nerve physiologyAcupuncture in MS

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