A 55-year-old patient complains of lower back pain due to heavy lifting at work yesterday. He reports weakness of the left leg and paresthesias in the left foot
On physical examination, the patient has diminished ability to dorsiflex the left ankle. Which of the following symptoms should prompt the clinician to make immediate referral to a neurosurgeon?
A. Straight leg raising sign
B. Lumbar herniated disc on x-ray
C. Loss of left sided patellar reflex
D. Urinary incontinence
ANS: D
With low back pain in a patient, it is important to obtain a detailed history of the onset and progression of the pain. A thorough pain history should be completed, noting its quality, location, radiation, and intensity as well as any exacerbating and relieving factors. A thorough review of systems is necessary to identify any associated symptoms that may indicate an urgent problem. These include altered bowel and/or bladder function, fever, weight loss, and/or weakness. The physical examination should begin by noting the patient's posture and apparent level of comfort. The standing patient should be directed through a series of maneuvers to assess the back motion, including flexion, hyperextension, lateral flexion, and rotation, as the smoothness of motion, ROM, and any obvious signs of discomfort are noted. Observe the patient walking on heels and on toes, noting any signs of weakness. Next, with the patient resting supine on the examination table, the straight leg maneuver should be performed. As the patient rests supine with both legs extended, the examiner should passively elevate one leg at a time. A positive test is indicated if the patient experiences discomfort with the initial elevation rather than once the hip has been hyperflexed beyond 50 degrees. If the results indicate nerve impingement or disk injury, further radiographic testing is then indicated.
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