When a patient comes to me with low back pain that radiates down their leg, then I know I have the potential to affect their quality of life in a dramatic way. This is the line between having great results from conservative therapies in a chiropractic office, and more invasive surgical procedures.
When you come in to my office and you are leaning to one side because of the pain, then I know you have a disc problem. Some of the physical exam procedures that I do will help us figure out where exactly that problem is. Nerve root? Sciatic nerve?
Radicular: Irritation or compression of the nerve root. It could be L4, L5, S1, S2, or S3 nerve roots
Sciatica: Irritation or compression of the sciatic nerve after these nerve roots leave the lumbar spine and converge together into the thick sciatic nerve.
When we do orthopedic or neurological tests to find out where a nerve compression is, you are experiencing stretches and compressions on multiple parts of your body. In your spine. blood vessels. discs. facet joints. nerves. So, orthopedic tests have varying sensitivity and specificity. They’re not perfect. But, we combine the best tests to increase our clinical certainty.
Miller, 2007, recommends that low back sciatica tests be done in a seated position, even though most tests are done supine. A seated position really puts pressure on the disc, and it is often the position where you feel the pain the most.
A patient’s antalgic lean can tell me a lot about the nature of the herniated disc. If you are leaning away from your pain, then you are telling me about your problem. Must disc problems go to the back and the side of the disc. Posterolaterally. Away from the center of your body. And once it’s to the side, the protrusion from your disc will be to the inside or the lateral side of the nerve root.
A medial disc herniation is a disc that goes to the inside of your nerve root. A lateral disc herniation is a disc that goes to the outside of your nerve root. They are both lateral to the midline of your body. If you have a lateral disc herniation, you’ll want to lean away from the side of the herniation. If you have a medial disc herniation, you’ll want to lean towards the side of the disc.
Lumbar Lateral Bending
Miller recommends doing the classic Kemp’s test in a seated position, while most people do this standing. Kemp’s test will challenge your discs by bending you to ones side with or without rotation to see what position will aggravate the disc. The seated poison increases intradiskal pressure, and it also stabilizes the pelvis and legs to take out any confounding variables.
When seated, you are automatically in hip flexion. When you extend your leg, and you feel pain, this is a positive seated Lasegue test. When you are on your back, and I flex your hip, then extend your knee, this is a positive supine Lasegue test. When your leg starts out straight, and I keep it straight as I flex your thigh, this is a straight leg test. Both of these tests, supine or seated, end up in the “jackknife” position.
Flexing the neck can produce tension along the spinal cord dura mater lining, and can reproduce disc symptoms. Depending on your symptoms, this can help differentiate other problems in your spine that may arise.
Hip Internal Rotation
Internal rotation at the hip stretches the piriformis muscle. The piriformis muscle is involved sometimes with sciatica. It can tighten and pinch around the sciatic nerve.
Pulling your straight leg across your body will stretch the sciatic nerve. The Bonnet test is a straight leg raise, hip adduction and hip internal rotation.
Dejerine Triad and Valsalva
The Valsalva maneuver is when you strain while holding your breath. This increases the pressure in your disc and spinal cord lining. It’s like the strain when you have a bowel movement. Dejerine’s triad is couching, Valsalva, and sneezing. These tests can also point to other space-occupying lesions in your central nervous system, like a tumor. But, a tumor would have different symptoms than regular sciatica.
If you have pain, or numbness and tingling down your leg, then it’s important to find a doctor who has an understanding not only of what named tests exist on a sheet of orthopedic tests, but they must also understand the mechanisms behind the test. Doing so helps isolate the cause and mechanism of the pain or compression, and it can help with a more efficient recovery.
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