Low back pain
With gait, when you look at this, this is your quick and dirty neurologic assessment; of you ask a patient with back pain to flex and extend and ask which one hurts more, if they hurt more in flexion you are thinking maybe it’s discogenic because you are raising intradiscal pressure, if they hurt a little bit more in extension where degenerative disc should feel better, then maybe it’s facet or something else, all of a sudden, you are all of a sudden focusing on a mechanical differential, and then you do a quick and dirty neurologic. You check the Trendelenburg maneuver, you have them heel and toe walk, what have you just done, you have tested the neurologic integrity of L4-5 and L5-S1, the three most commonly involved roots. With the Trendelenburg, you check the gluteus medius 5-1, heel walking with the gastrocsoleus, you are checking S1, toe walking you are checking L4-5, so if they can do that, you have already ruled out a catastrophic neurologic deficit and you have a mechanical differential and within 20 seconds, you will have gained more information than most people who are approaching this problem will, and it’s a very, very easy thing to do.
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If we look at the kinematics of the spine, it becomes very, very clear that we were not designed to walk upright. This is clearly a design flaw. If you look at the range of motion of the lumbar spine, 90% of the flexion extension comes from the L4-51 segments, that doesn’t make any sense if you are walking as an upright biped because those support most of the load of the torso, the trunk in an upright posture, so it clearly is rather silly from a point of view mechanical design to have the floppiest segments the most heavily loaded, so that’s one problem. The second problem, if you look at the arrangement of the cauda equina, the only segments that are crossed by multiple extra thecal nerve roots are L4-5 and 51, so if there is posterior protrusion of the disc, you are far more likely to entrap a nerve root there than you would be at more rostral segments, so there are lots of reasons why 90% of the pathology of the low back is at L4-5 and 51. Clearly, it would be better in this particular instance if we weren’t bipedal because this is clearly a design flaw. Now keeping some of those things in mind, you can understand that if someone is a little bit better in extension, you are thinking about a discogenic source of back pain, lordosis is preserved, intradiscal pressure is lower, those people tend to be better standing than sitting.
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If someone is better in flexion, a spondylolysis, spondylolisthesis, something facet mediated, posterior column, or in some body with some sort of nerve root entrapment, usually in the intervertebral foramen. The other differential for flexion is somebody with spinal stenosis, but that is a neurogenic claudication, kind of a different category and we will get to that in just a second.
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