So when you have compression of the nerve roots,
sometimes that could cause muscle weakness.
So, compression of the S1 nerve root which innervates
your Achilles can sometimes cause a foot drop.
This could also be mimicked by compression
of the common fibular nerve.
So, you could have central compression
of the nerve in the nerve root
at the spine due to disc herniations.
But you have to differentiate that
from possible peripheral impingement.
So if we have peripheral impingement of the
common fibular nerve at the fibular head,
where you could have the fibula
positioned more posteriorly
because that nerve lies right posterior
to the fibular head,
that could lead to compression of the nerve
causing a possible foot drop.
So it mimics the same.
So when you have certain findings,
you also then have to differentiate
between the central cause versus
the peripheral cause of nerve injury.
So some pearls to think about if we have
lumbar disc degeneration and herniations.
Not all disc herniations have to
In fact, 95% of those in the younger
population may totally be asymptomatic.
Nerve root symptoms are typically
on one side.
So if you have a herniated disc,
it's very rare to have bilateral symptoms.
In fact if you do have a bilateral
or saddle innervation issues
then you have to think about
compression of the nerve roots,
the cauda equina syndrome
which is a surgical emergency
So usually if you see a
it's usually gonna be at one side only,
usually not both sides.
You definitely have to correlate what you're
finding with what the patient is explaining
in terms of duration of symptoms,
history of trauma, history of injury
and also correlate that with
what's found via imaging.
Disc herniations again is only just one
reason for nerve impingement.
There could be many different causes of
nerve impingements such as muscle spasms.
You could have piriformis syndrome where the sciatic
nerve is compressesd by a spasmed piriformis muscle.
So don't think that every single nerve issue
is because of disc herniations.
And not everything that radiates down
the leg is due to just a nerve root.
As we mentioned before, piriformis
syndrome or other compressions
such as the common peroneal
nerve from the fibular head.
Some pitfalls in evaluation when
you're evaluating the lumbar spine,
If someone comes in and they're severly injured,
you don't want to make them do the works.
So you don't want them to do
any sort of active range of motion.
Sometimes if you have suspicion to think that there
is a fracture or some sort of injury in the area,
you don't want to induce
too much flexion or extension,
especially if someone has severe
osteoporosis or some sort of fracture.
You always want to take an
X-ray first in that case
and make sure you rule those
If you don't perform an adequate
orthopedic or neurological exam,
you may miss some of the signs
and symptoms that may come along
with nerve root issues or orthopedic
And not performing a structural exam, tying in all
the key structural findings of somatic dysfunctions
that could tie in to lower back pain
and similar presentations.
One of the things that could help in the
evaluation of low back pain is to take an X-ray
and if you take an x-ray from
the lateral view to take a look
at the lumbosacral angle or
also called the Ferguson angle.
What this angle does is that it gives you
approximate amount of lumbar lordosis
and potential indication of whether or not there
is an issue contributing to the low back pain.
So, this angle is formed where you draw a
line between the inclination of the sacrum
to a horizontal line, usually
it's like 25 to 35 degrees.
If you have an angle greater than that, that's usually
due to increased stress at the lumbosaccral joint.
Again, increase in lordosis if you
where you have weakness of the
anterior abdominal muscles
or just obessity or pregnancy at times
will increase that lumbar Ferguson angle.
That lumbosacral angle also has a big part to do
with the muscles and muscle tightness in our back.
And so, there are certain muscles
in our body
that tend to be more spasmed
and tight with overuse.
And there are certain muscles in our body
that tends to get more weak and inhibited.
And so, around our pelvis, we have our
erector spinae muscles in the back
and our hip flexors, the ilipsoas
and rectus femoris.
These muscles going from the back to the
frontier tend to become tighter when spasmed.
Whereas our abdominal muscles and our
gluteus muscles in the back here
tend to become inhibited and
weaker with stress.
And so you could see how
this kinda creates a cross
and so they call this the "lower cross
syndrome" where our muscles in our back
and our hip flexors become tight and our
abdominal muscles and our gluteal muscles
become weaker leading
to increased Ferguson angle.
The anterior abdominal muscles here play
a big part in supporting our lower back.
And so we talked about having a core or
cylinder surrounding our lumbar spine
and so weakness of this abdominal
muscles or transversalis
can play a part in lower back pain also and
is usually a key part in actual recovery
to have the patients try to
strengthen their abdominal muscles
and if needed, to lose weight to decrease
some of the strain at that area.
So when evaluating lower back pain,
causes and issues,
there are some key things that can aid you
with diagnosing the causes of lower back pain.
So if patient comes in and they're complaining
of increased pain with walking and twisting,
that could be musculoskeletal,
some sort of strain.
If a patient says that their
pain decreases with sitting,
or if you bend towards where
that actually increases a lot
when they're standing up straight
or trying to lay flat in bed,
then we have to think about possible
psoas syndrome or psoas muscle spasm.
If they complain of increased pain
with sitting or lumbar flexion,
you have to think about possible
especially if the pain is shooting
and more unilateral than bilateral.
Increased pain with lumbar extension-
this might be more of a facet joint issue
cause you're closing the joint, and if the joint
is inflammed, that could make the pain worse.
Additional considerations to think about
other things that contribute to pain
lower back pain include posture, muscle weakness,
sacrum or pelvic or lower extremity dysfunctions
Having a leg-neck discrepancy is
gonna cause uneveness at the pelvis
which lead to side bending in
the lumbar spine to compensate.
And there's definitely certain things that could
cause low back pain that's non-mechanical.
Pain that is worse at night or doesn't really
get any better with movement or positioning,
you do have to think about
Tumors from the prostate, especially
it spread to bone really rapidlly.
And also, lower back pain and stiffness
that's worse really in the morning,
tends to be more rheumatological.
If you have pain associated with
fever or chills,
that might also be infection or
a bone infection.