- Introduction: The importance of a good history taking.
- Where is the pain – centralisation?
- The typical stories
- “Hard” protrusion / internal derangement
- “soft” protrusion / internal derangement
- “Mixed” protrusion / internal derangement
- Nuclear self-reducing disc protrusion / internal derangement
- Bruised dura mater
- “Mushroom” phenomenon and Spondylolisthesis
- Size of the internal derangement
- What about paraesthesia?
- Influence of coughing / sneezing
- Danger to the S4-nerve root
Low back pain history taking
Introduction: The importance of a good history taking.
When a patient is suffering from back pain, we can extract a lot of useful information from the history taking. In certain cases both diagnosis and treatment strategy are known before starting the clinical examination, just by listening carefully to the patient.
By means of a good history-taking we try to find out whether the patient suffers from a disc protrusion /internal derangement, or whether he has another pathology.
If there is an internal derangement, we have to establish it’s nature : big or small, more annular or nuclear, central or lateral, reducible or not, dangerous or not ?
We always expect a connection between the patient’s symptoms and certain activities, postures, movements. We look for inherent likelihoods and are particularly on our guard in the case of inherent unlikelihoods.
Generally speaking, the history informs us about :
- age, profession, hobby, ADL
- influence of coughing
- danger to the S4-root
- personality of the patient.
Where is the pain – centralisation?
Central, uni-, or bilateral pain ?
- A unilateral structure cannot cause central pain. A disc protrusion / internal derangement can cause central, uni- or bilateral pain.
- We must clearly distinguish a shifting pain from an expanding pain. A shifting pain results from a shifting lesion, most likely an internal derangment. --> Example : facet joints cannot cause pain on the midline, nor they cause shifting pain.
“Centralisation” of symptoms is an important and favourable clinical finding.
Centralisation implies :
- This is a reliable predictor of good or excellent treatment outcome.
- If extension reduces the complaints and causes a centralization then this is a good predictor for non surgical intervention.
- A number of studies have linked centralization to discogenic problems, or non-centralization to non-discogenic problems.
- Centralization is not associated at all with positive responses to facet joint blocks
- Significant association between a positive discography and the occurance of centralisation (p or peripherilisation (p
- Centralization was significantly associated with an intact annulus (p
- In studies comparing MRI or CT findings centralization commonly occured in patients with extrusions and sequestrations à this is a rather surprising finding.
Conclusion : centralization is generally, but not universally, associated with a good prognosis, but this effect declines in certain subgroups
The upper lumbar region is considered as a so-called “forbidden area”, because disc protrusions are less frequent in this area and other pathologies (e.g. metastases) are more frequent than in the lower lumbar area.
Alternating buttock pain
Alternating buttock pain could characterize an acute symptomatic phase of an ankylosing spondylitis, in which both sacroiliac joints are involved.
Leg pain - dural reference or nerve root compression?
A patient describes pain in the leg : is it the result of a “sciatica” or is it rather related to dural compression ? In other words, is there compression of a nerve root or compression on the dura ?
>>> How can we know ?
We ask the patient what he feels in the lumbar spine.
If he answers : “the lumbar pain is always there, but sometimes I feel also a pain down the
leg”, this is clearly dural multisegmental reference of pain. If he states that the pain used to be lumbar, but now he only feels it in the lower limb, this is rather a shifting pain pointing in the direction of compression on a nerve root.
>>> Why do I want to know ?
In case of a lateral protrusion with pressure on a nerve root i.e. a sciatica, (in a patient under 60y), there is a mechanism of spontaneous evolution which takes about 8-12 months.
This implies that the symptoms disappear within this time frame, without any treatment.
The important message however is that the protrusion becomes irreducible in the second half of the spontaneous evolution, so, after 6 months of leg pain (without back pain !). In that phase manipulative treatment has become obsolete.
Bilateral root pain, i.e. pain in both lower limbs and not in the back, is probably not caused by a disc protrusion. More likely are spondylolisthesis, metastases or the mushroom phenomenon.
The typical stories
In case of a symptomatic internal derangement, we expect the symptoms of the patient to be related to certain movements, postures, activities.
“Hard” protrusion / internal derangement
While doing e.g. a flexion-rotation movement the patient states that “suddenly” he feels a twinge in this back, resulting in back pain and possibly limitation of movement or even a deviation fixation in flexion or a lateral deviation.
The sudden appearance of pain points in the direction of a more annular or “hard” protrusion.
In that case the patient seem to react better on certain manipulation techniques.
“soft” protrusion / internal derangement
A patient has been doing quite a lot of flexion or flexion-rotation activities after which he feels that a lumbar pain comes on slowly (“my muscles feel sore”), becoming much worse the next day.
A rather slow onset of pain point more in the direction of a more nuclear “soft” protrusion. A nuclear bulging through an intact, but possibly, damaged annulus.
This story reacts better on continuous mechanical traction instead of manipulation.
“Mixed” protrusion / internal derangement
The image of a “mixed” protrusion is quite frequent : either the patient has some diffuse aching which appeared spontaneously, and, when performing a certain movement, he feels a sudden increase of pain.
Or, an ache appeared suddenly, during a movement, and increases slowly in the next few hours.
Thus, the combination of a slow and sudden onset.
In that case, perhaps, we treat by manipulation and continuous mechanical traction.
Nuclear self-reducing disc protrusion / internal derangement
The patient is young (20-40y). He wakes up painlessly in the morning , in the course of the day he gets backache which increases gradually ; he has more pain in the evening. When he lies down or does some other activities, the pain ceases quickly. This sequence of events is repeated day after day.
This is the result of unergonomical activities and postures, with too much unfavourable loading on the lumbar spine.
When the patient is changing the loading on the spine, the symptoms disappear automatically.
Due to the unfavourable loading, minor internal derangements can occur (see also the chapter on “Postural syndrome”), but they reduce automatically by changing the position.
So, this patient doesn’t need manipulation or traction, he needs to the point preventive information.
This is a beautiful example of the value of the history : the history provides the diagnosis, while the clinical examination is hardly relevant : it is negative in the morning and possibly positive in the afternoon or the evening.
Bruised dura mater
Imagine a chronic back pain patient : he suffers intermittently from back pain since e.g about twenty years ; sometimes the describes the typical history of a internal derangement. He knows which kind of treatment or exercises can help him, he knows which movements or positions are favourable.
But, a certain moment, his typical story is changing. Probably the patient is over 50 years old now, but now he mainly complains about nocturnal or matutinal pain (e.g. half an hour every morning), and during the day he has no discomfort.
The pain is unrelated to posture or exertion and the lumbar test are negative.
This is not anymore a “mechanical” story but rather an inflammatory story.
Some patients stated that a cough provoked pain in the back only when they had their backache (at night or in the morning). This being a dural symptom, it made sense to Cyriax to try a local epidural anaesthesia diagnostically ; in most cases, one single injection proved curative.
Hypothesis ? There has been an intermittent mechanical problem for years (recurrent internal derangement) ; now, the derangement seems to be reduced (the lumbar movements are normal), but the dura mater remains, irritated or “bruised” because of the repetitive bulging against the dura. So, because of the epidural injection, the bruised dura mater is desensitized and/or the local inflammation is reduced.
“Mushroom” phenomenon and Spondylolisthesis
We hear a typical history :
pain (in the back or in both lower limbs) on standing and walking, disappearing almost immediately on sitting or lying,
When the patient is older we first think of a mushroom phenomenon ; in younger patients a symptomatic spondylolisthesis is more likely.
The mushroom phenomenon ?
The patient has a fully eroded disc. Almost the entire disc substance has moved anteriorly (anterior protrusion). The tension in the posterior longitudinal ligament has become “loose”, in a standing position, it bulges and compresses the dura and/or the nerve roots. Bending forwards, sitting or lying tautens the ligament again, the compression on dura and/or roots ceases and the pain disappears.
An anterior shift of L5 on S1, which is the result of degeneration or trauma ; it could also be congenital.
Overtraining in sports involving hyperextension (gymnasts, baseball) could also play a role.
In the inspection excessive skin folds above the defect can be observed.
In the examination passive extension pressure in lying can be painful as well as a painful and limited extension in standing.
We can find a “shelf” when palpating along the spinous processes.
It occurs in approximately 5% of adults and is symptomatic in only 50 % of the cases.
Size of the internal derangement
Whether an internal derangement is large or not, it very important in relation to the treatment. Some protrusions are too big to be reduced by manipulation, traction or exercises. It is an illusion to think that we can reduce each protrusion by manipulation, exercise or mechanical traction.
In the history we can already hear some indication about the size of the protrusion.
- At first the patient describes some back pain, followed by S1-root pain. The patient states that, in the last few days, he lost sensation in the fourth and fifth toes. This is a sensory deficit, which means that the protrusion has become bigger and therefore probably irreducible.
- A patient with an S1-sciatica complains about recurrently spraining his ankle in the last couple of weeks. This suggests a motor palsy of the peroneal muscles, again indicating that the protrusion probably has become irreducible.
- A patient with an L4-sciatica states that, after walking for some time, he has difficulty in lifting his foot : probably due to a motor palsy of the tibialis anterior muscle. (differential diagnosis : tight fascial compartment.)
What about paraesthesia?
Pins and needles, numbness ?
When a disc protrusion compresses the nerve root, the first symptom is pain. More pressure results in paraesthesia as a second symptom, possibly followed by numbness and deficit.
It’s interesting to know if there paraesthesia with or without pain ?
When we think of a posterolateral disc protrusion compressing a nerve root, we expect pain first and then possibly paraesthesia.
Paraesthesia without premonitory pain suggests there is no compression on the nerve root, in the foramen intervertebrale, but a compression more distally on the nerve trunk, thus excluding an internal derangement. In that case we could think of e.g. a thoracic outlet phenomenon.
Influence of coughing / sneezing
We assess the influence of coughing on the patient’s symptoms. There are three possibilities:
- a cough hurts in the back : this is interpreted as a dural symptom, pointing in the direction of a symptomatic internal derangement
- When the pain is felt in the lower buttock, a sacroiliac arthritis is possible.
- Pain in the lower limb on coughing suggests a neuroma or a primary posterolateral protrusion (PPLP).
Danger to the S4-nerve root
As already mentioned above, a lower lumbar central disc protrusion can endanger the
S4-nerve root. The pain is felt in the S4-dermatome. More pressure results in paraesthesia in the genitals, weakness of the bladder and rectum and analgesia in the saddle area. The history is much more important than the clinical pattern, which can be rather variable.
Particularly in three specific cases we must make inquiries about a possible S4-danger :
- acute lumbago : because this is always a large protrusion
- coccygodynia (S4-pain ?)
- bilateral sciatica : this is probably not a disc protrusion, but it could, exceptionally, be a large bilateral protrusion
A patient with S4-symptoms or -signs should immediately be referred to the medical doctor. It is imperative to avoid at all times a cauda equine syndrome.