From a sitting or standing position, palpate the spinous processes of each vertebra with your thumb.
In the neck, also palpate the facet joints that lie between the ceivical vertebrae about 1 inch lateral to the spinous processes of C2-C7. These joints lie deep to the trapezius muscle and may not be palpable unless the neck muscles are relaxed.
In the lower lumbar area, check carefully for any vertebral "step-offs" to determine if one spinous process seems unusually prominent (or recessed) in relation to the one above it. Identify any tenderness.
Palpate over the sacroiliac joint, often identified by the dimple overlying the posterior superior iliac spine.
You may wish to percuss the spine for tenderness by thumping, but not too roughly, with the ulnar surface of your fist.
Inspect and palpate the paravertebral muscles for tenderness and spasm. Muscles in spasm feel firm and knotted and may be visible.
With the hip flexed and the patient lying on the opposite side, palpate the sciatic nerve, the largest nerve in the body, consisting of nerve roots from L4, L5, SI, S2, and S3. The nerve lies midway between the greater trochanter and the ischial tuberosity as it leaves the pelvis through the sciatic notch.
Tenderness suggests fracture or dislocation if preceded by trauma, underlying infection, or arthritis.
Tenderness occurs with arthritis, especially at the facet joints between C5 and C6.
Tenderness over the sacroiliac joint pinpoints a common cause of low back pain. Ankylosing spondylitis may produce sacroiliac tenderness.
Pain on percussion may arise from osteoporosis, infection, or malignancy.
Spasm occurs in degenerative and inflammatory processes of muscles, prolonged contraction from abnormal posture, or anxiety.
Sciatic nerve tenderness suggests a herniated disc or mass lesion impinging on the contributing roots.
Palpate for tenderness in any other areas that are suggested by the patient's symptoms. Recall that low back pain warrants careful assessment for cord compression, the most serious cause of pain due to risk of paralysis of the affected limb.
Herniated intervertebral discs, most common between L5 and S1 or between L4 and L5, may produce tenderness of the spinous processes, the intervertebral joints, the paravertebral muscles, the sacrosciatic notch, and the sciatic nerve.
Rheumatoid arthritis may also cause tenderness of the intervertebral joints.
Remember that tenderness in the costovertebral angles may signify kidney infection rather than a musculoskeletal problem.
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