When a patient presents with lower back pain, nerve tension often indicates a disc herniation. There are many good ways to test for a low back disc. I have previously talked about observing the patient presentation of antalgia,1 looking for a short leg2 or individual tests such as the straight leg raise.3 Recently, I was shown a great combination of tests that is a great way to test for nerve tension in the lower back.
While the patient is seated, have them raise the leg of primary complaint – this is the Lesegue sitting test. If this produces pain, have them drop the leg a few degrees and flex the toes up – Braggard's test. If pain is again reproduced, you likely are dealing with sciatic nerve inflammation.
If there is no pain on the primary leg, have them raise the good leg – this is the well leg raise test. If this produces pain, instruct them to drop the leg a few degrees and flex the toes up – Fajersztajn's test. If both tests are positive, the indication is a space-occupying mass in or near the axilla of the nerve root.
If these tests are negative, have the patient raise both legs together – bilateral leg straightening. Again, if this produces pain, have them drop the leg a few degrees and flex the toes of both feet up to stretch the nerve roots and localize the source of pain.
If these tests are negative, then with the legs still extended, have the patient drop their head to their chest – Soto-Hall. This puts further traction on the spinal cord and nerve roots. This can be further accentuated by instructing the patient to lean forward (the slouch), and then a little more with coughing (Valsalva's).
At this point, you have put maximal stretch across the lower spinal cord and lower-back nerve roots. Pain with any of these maneuvers warrants further orthopedic evaluation and appropriate imaging. If all these tests are negative and there is no reproduction of leg or back symptoms, there is little indication of dural tension and you can look to other causes for lower back pain complaint.
This many seem like a long list of tests, but they can actually be performed in very short order and provide a wealth of insight regarding the source of your patient's lower back pain. Such notes are also invaluable when documenting your patient's complaints and the extent of the irritation. When there is pain, always note where the pain goes. Is it in the back, the buttock or the leg? Does it go down to the knee or foot? Does it cause tension or pulling up into the neck?4
As I've emphasized in previous articles, this extra documentation can help make the difference if you must justify your diagnosis to an insurer or third party. Take the extra few seconds to add these tests into your exam routine – they will serve you and your patients well.
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Additional Resources
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