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SYSTEMATIC DIAGNOSIS IN BACKACHE.

WENTWORTH, EDWARD T.
The Journal of Bone & Joint Surgery: January 1926
Archive: PDF Only

'Opinion' must give way to 'Systematic Diagnosis.'

The many pathologies may give rise to similar complaints of pain, weakness, and limited motion, but systematic search reveals discriminating objective evidence of many distinct lesions.

Only a very few cases leave 'injury' out of the history.

As a rule histories of radiating pain are inaccurate and of very little differentiating value as compared with subjective location of constant pain.

Sciatic pain is not necessarily sciatica, but may be.

Exaggeration is as common as malingering is rare.

Spinal deviations are of little or no differentiating value.

Posture, including the feet, is an important element in static backs and static sacro-iliac strains.

The flat lumbar spine is common in sacro-iliac subluxation.

It takes a marked degree of limitation in spinal flexion to be of differentiating value.

The age factor must always be borne in mind when considering range of spinal flexibility.

Pain in the back on straight leg raising must occur before the extremity reaches 135 degrees to be of much differentiating value. Above that almost any low back pain will be aggravated.

Pain on thigh hyperextension has no differentiating value.

Audible clicks are not pathognomic of sacro-iliac relaxation.

Reduction of subluxation is a definite scientific procedure evident to both patient and surgeon when obtained.

The subluxation is a more severe lesion than the strain, has more direct relationship to trauma, and quicker pain reactions to manipulations.

Pain on crest compression is limited to sacro-iliac cases, but is not always present in them.

Radiography is absolutely essential in any complete differential diagnostic procedure.

Altered reflexes, muscle atrophies and paralyses, localized clonic contractions, trophic changes, areas of decreased or altered tactile sensibility and hyperalgesia are important in neuritis, perineuritis, radiculitis, and nerve injury, but not in bone and joint lesions.

Areas of localized tenderness are of great value.

The diagnosis of fractures, dislocations, and osteoarthritis may be clinched by the radiograph.

The diagnosis of sacro-iliac subluxation may be proved by a manipulative reduction.

The differentiation between lumbo-sacral and sacro-iliac strains, after all is said and done, depends upon a very few findings: location of the pain and the tenderness, occupation, pain on straight leg raising between 180 degrees and 140 degrees, and on crest compression. Radiography may be of value, but is not essential.

Cases of traumatic strain limited to lumbo-sacral or to sacro-iliac ligaments are rare. In most cases of traumatic strain both sets of ligaments are involved.

The diagnosis of static strain depends upon absence of definite lesions in the presence of poor physical condition or bad body mechanics. Congenital bone anomalies of the lumbo-sacro-iliac region may be contributory factors in many lesions, but the physiologic balance maintained by muscles and ligaments is of more importance than the anatomic bone structure. [See the Chart I in Source Pdf.] [See the Chart. II in Source Pdf.] [See the Chart. II-(Continued from preceding page) in Source Pdf.]

Logic and the preponderance of evidence at the present time are against sacralization and large transverse processes being the etiologic factor in back pain, except through unusual leverage action and consequent ligamentous strain.

The diagnosis of nerve injuries, muscle injuries, bursitis, tuberculosis, and neoplasms requires no special comment.

The field of neuritis and perineuritis is covered by the nerve findings.

Syphilis, the personality of the individual, the economic and social backgrounds must never be forgotten.

(C) 1926 All Rights Reserved.The Journal of Bone and Joint Surgery, Inc.

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