Low back pain is the most common clinical condition after the flu, but it involves many factors and is difficult to diagnose. Detailed history taking and physical examination have an important role in the diagnosis of low back pain. Questioning: 1. Site of pain It is important to have the patient point out the site of pain with his finger because the patient’s knowledge of anatomy is superficial; many patients think that below the neck and above the hip is the low back, and some patients say that for back pain he may be referring to the shoulder nail area. The way the patient describes the site of pain is sometimes important for diagnosis. Emotionally stable patients, hush often describe the path of pain radiation by placing the palm of their hand back and forth over the area where the pain is most pronounced. In contrast, a fraudulent or emotionally unstable person often has the thumb pointing out the area of pain, and he never touches the painful area. Radiation to the leg is an important somatic condition. Entrapment pain rarely involves below the knee joint, whereas nerve root pain usually involves below the knee joint. The diagram below shows the localization of the responsible nerve root (L1 to S1). The relationship between leg pain and low back pain is generally greater for nerve root pain leg pain than low back pain. Questioning: 2. Effect of activity on pain It is best to ask the patient the following questions in detail: 1. does it hurt when standing up. 2. does it hurt when bending over. 3. does it hurt when getting up or turning around. 4. does it hurt when resting. 5. does it hurt when going up and down stairs. 6. does it hurt when standing or sitting for a long time. 7. what do you do when the pain worsens? Lie down, stop, sit down or walk around. These questions are significant to our diagnosis. In general, pain of mechanical origin will be aggravated by activity and relieved with rest, such as discogenic pain. Pain in small joints can be exacerbated by rising in the morning, during sudden turning and bending. In contrast, visceral involvement pain is not aggravated by activity and is not relieved by rest, such as duodenal ulcers. In contrast, neurofibromas that accumulate nerve roots often require constant walking to drive away the pain. Tumor-based pain is less related to activity and is more common with resting pain and nocturnal pain. Interrogation 3: Duration and course of pain. We may want to ask the following in detail: When did the pain start? How did the pain start? Was there any trauma before the pain started? Are there other triggers for the pain? Did the pain get progressively worse or did it come on suddenly? Is the pain persistent or episodic? Is there a visible pattern of pain? Is the pain increasing in severity, including frequency, intensity, and duration of episodes? For example, severe paroxysmal pain after strenuous activity is mostly caused by mechanical factors. And severe pain after mild exercise should be considered case fracture, such as osteoporotic patients can move heavy objects to cause lumbar compression fracture, and elderly people over 60 years old should not forget the possibility of tumor. Questioning 4: Degree of functional limitation The degree of symptoms and functional limitation can help us distinguish whether the patient’s disability is more minimal, moderate or severe, and a clear grading helps us to develop a mediated treatment plan. If a patient is incontinent, then there is likely cauda equina compression, which is a clinical emergency that requires emergency surgery to relieve the compression and cannot be treated conservatively. If a patient with cervical spondylosis has leg discomfort or a feeling of stepping on cotton, it indicates that the spinal cord is severely compressed, and general minimally invasive surgery may not be able to help, and decompression surgery is needed. The symptoms of low back pain with spinal deformity, post-traumatic deformity is mostly due to spinal fracture and misalignment; since childhood, deformity is mostly due to congenital spinal disease; slow onset is seen in spinal tuberculosis and ankylosing spondylitis. 2, low back pain with restricted movement is seen in spinal trauma, ankylosing spondylitis, acute sprain and contusion of soft tissue in the low back. 3, low back pain with prolonged low fever is seen in spinal tuberculosis, rheumatoid arthritis; rheumatoid arthritis; low back pain with prolonged low fever is seen in spinal tuberculosis. Low back pain with prolonged low fever is seen in spinal tuberculosis, rheumatoid arthritis; with high fever is seen in septic spondylitis and paravertebral abscess. 4, low back pain with frequent urination, urinary urgency and incomplete urination is seen in urinary tract infection, prostatitis or prostate hypertrophy; low back pain with hematuria is seen in kidney or ureteral stones. 5, low back pain with belching, acid reflux and epigastric distension is seen in gastric and duodenal ulcers or pancreatic lesions; low back pain with diarrhea or constipation is seen in ulcerative colitis or Crohn’s disease. 6, low back pain with abnormal menstruation, dysmenorrhea and excessive leucorrhea are seen in cervicitis, pelvic inflammatory disease, ovarian and adnexal inflammation or tumor. For the past examination and treatment, we should learn to analyze and look at the problem dialectically, we do not need to do it again for the patient’s previous formal treatment, but it is necessary to do it again for the irregular treatment. The effect of the formal treatment can also help us to identify the disease well. Physical examination1 Visual examination Gait examination. Observe the patient walking. Is there a gait that avoids pain, such as a painful hip or knee gait? Is there a gait with nerve damage, such as stiffness or spasticity? Is there a shopping cart position that suggests spinal stenosis? Is there claudication through longer periods of walking? Spinal profile. The spine should be observed posteriorly and laterally for deformities. Skin signs:Skin pigmentation spots are a sign of neurofibroma. Lipomas or hirsute spots in the lumbosacral region may suggest deep bony deformities such as invisible spina bifida with or without concomitant neurofibroma (embolism syndrome). Range of motion and rhythm. It is important to observe the range of forward flexion, retroversion, lateral flexion and rotation, and also to note the rhythm. These tests are used to observe specific deformities, such as:Significant limitation of spinal forward flexion under quiet conditions of lumbar stiffness is commonly associated with radicular pain due to disc herniation. Such patients tend to favor the painful side of the spine when moving in forward flexion. Full spinal stiffness is a characteristic feature of advanced ankylosing spondylitis. Abnormal rhythm with forward flexion and posterior uprightness is a characteristic sign of and and small joint injury. Muscle strength examination. Repeated tiptoe and tiptoe heel movements (fatigue test) can be done more than 10 times rapidly under normal conditions, and if less than 10 times can suggest some early lesions. Abnormal tiptoeing on the heel suggests compression of L5, and abnormal tiptoeing on the toe suggests compression of S1. The presence of knee flexion on tiptoe suggests decreased quadriceps muscle strength and possible femoral nerve irritation. Physical examination 2 Reflexes Enhanced knee reflexes are most often seen with conus fasciculus damage, and highly hyperactive knee reflexes can often be accompanied by binocular clonus. Diminished knee reflexes suggest damage to the femoral nerve L2-L4. Abnormal ankle reflexes suggest damage to S1 of the sciatic nerve. It is important to note that the tendon reflexes are more disturbed by consciousness and can be enhanced if necessary. The method is as follows: the patient is asked to hook the fingers of both hands together and pull hard to the outside, at which point the examiner’s percussion tendon reflex will be higher than usual. Physical examination 3 Pathological signs. 1.Babinski’s sign: the patient is lying on his back with the lower limb straight, the doctor holds the ankle under examination and uses a blunt-tipped bamboo stick to scratch the lateral edge of the sole of the foot, from posterior to anterior to the heel of the little toe and turns to the medial side, the normal reaction is plantar flexion, the positive reaction is dorsal extension of the bunion and the rest of the toe is fan-shaped spread. 2.Chaddock’s sign: Use a bamboo stick to scratch the outer edge of the dorsum of the foot below the outer ankle, from posterior to anterior to the toe-metatarsal joint. 3.Oppenheim’s sign: The physician uses the thumb and index finger to apply firm upward and downward pressure along the anterior edge of the tibia being examined. 4.Gordon’s sign: The gastrocnemius muscle is squeezed with a certain force by hand during the examination. Positive pathological signs are mainly manifested when the conus fasciculus is damaged, but it should be noted that infants and young children have a positive expression under normal circumstances, and also after general anesthesia and patients in hypoglycemic coma often have positive pathological signs, so pay attention to the difference. Physical examination4 The examination of muscle strength. L5 nerve damage is the earliest to appear [long extensor muscle weakness, S1 nerve damage is the earliest to appear [long flexor muscle weakness. It is important to note that patients with radicular pain will have false positives when these antagonistic muscle strength tests are done due to increased pain, so the knee and hip should be flexed during the test. Physical examination 5 Examination of sensory abnormalities Physical examination 6 Nerve root signs Straight leg raise test: seems simple, but in fact there are many details that need attention. The steps of the examination are as follows: the patient lies flat and relaxed, the examiner holds the patient’s heel with one hand slowly (the leg lift should not be too fast, otherwise it will mask other symptoms due to sudden and severe pain) to raise the patient’s leg, the other hand is placed on the knee to keep the leg straight, when the leg or hip appears painful note the angle (injury to the low back causes N cord muscle spasm at this time will also appear painful), at this time the ankle dorsiflexion pain is increased (further This is followed by relief of knee flexion pain (further confirmation of radicular pain). Significance of the straight leg raise test on the healthy side: suggests that the protrusion is located in the axilla or inside the nerve root. Supine jerk test: In some dancers, theatrical acrobats or athletes, the ligaments of the joint are very lax due to long-term exercise, and when the straight leg is raised to 90°, it is often still unrestricted and painless, so the supine jerk test can be used to identify it. Practice is as follows: the patient is in the supine position, both hands on the side of the body, with the occiput and the two heels as the pressure point, the abdomen will be lifted upward, if you can feel lumbar pain and lower limb radiating pain on the affected side, that is positive. If the pain cannot be elicited, deep inspiration can be taken and held for 30 seconds while maintaining the above position until the face is flushed and the affected limb radiates pain is positive; or coughing hard while holding the abdomen, and the affected limb radiates pain is also positive. If the above methods cannot trigger the pain of the affected limb, you can also press the jugular vein with both hands or press the patient’s abdomen with your hands while the patient is holding the abdomen, and if there is pain in the affected limb, it is still a positive sign. The purpose of this test is mainly to distinguish some cases of false negatives in the straight leg raising test. Bowstring sign: This is probably the most plausible test for nerve root pulling. It is performed as follows: usually after doing the straight leg raise test to flex the knee pain is relieved by placing the patient’s lower extremity against their shoulder and then quickly pressing the sciatic nerve at the N fossa with the thumb, the patient with radicular pain will experience pain radiating to the lower extremity. If pressure on the N cord muscle also causes pain suspect that the patient has mental factors. Physical examination 7 Joint examination “4” test Operation method: The patient lies on his back, one lower limb is straightened, the other lower limb is placed in the shape of “4” near the knee joint of the straightened lower limb, and one hand presses the knee joint, the other hand presses the iliac crest on the opposite side, and both hands press down at the same time. When the pressure is applied, the sacroiliac joint appears to be painful, and the knee joint on the bending side cannot touch the bed is positive. Note the bilateral comparison. A positive result indicates a sacroiliac joint or hip joint lesion. The patient is placed in the lateral position and the ability of the lower extremities to abduct against resistance is examined. During the test, the gluteal muscles are strongly contracted to separate the sacrum from the pelvis. Patients with a sacroiliac joint lesion will experience pain. In the hip hyperextension test, the hip on the healthy side is flexed and the thigh is tightened against the anterior thorax to strain the lumbar spine. With extreme extension of the superior hip joint, the sacroiliac joint is hyperextended and patients with sacroiliac joint lesions present with pain. Physical examination8 Compression Pain Direct compression of the spinous process, the details of which are: the examination is not done by pressing vertically and forcefully, but by applying a downward and lateral force to the spinous process to produce rotation of the diseased segment, which is significant if it replicates the pain. In the case of pressure pain in small joints, the area of pressure pain often does not correspond to the area of pain complained of.