Diagnosis of osteochondrosis of the lumbosacral spine

Degenerative dystrophic changes of intervertebral disks in osteochondrosis of the lumbosacral spine, accompanied by one or another neurological symptoms, almost always accompany violations of the normal statics and biomechanics of the spine, which is especially evident in the lumbosacral region.

A clinical examination of the patient is carried out in a standing position:

• When viewed from the side, the degree of lumbar curvature change is determined (flattening of lordosis or the presence of kyphosis);
• The results of visual observation are confirmed by palpation of the spinous processes (by analogy with the thoracic region);
• When viewed from the rear, the type of scoliosis and its degree are clarified;
• The presence, degree and side of the tension of the long muscles of the back and limbs are determined;
• The volume of movements (active and passive) is investigated;
• The presence of pain during palpation of the spinous processes and interstitial gaps, as well as pain in the paravertebral points corresponding to the interjoint spaces;
• Determined myofascial pain points - TT.

[1], [2], [3], [4], [5]

Muscular system examination

[6], [7], [8], [9], [10], [11]

Muscles of the leg and foot

The movements in the joints of the foot are performed using the muscles, which are located on the lower leg in three groups: anterior, posterior, and lateral.

The back muscle group is 4 times stronger than the front. This is due to the fact that the foot is a lever of the 1st and 2nd kind depending on the position and function performed.

• At rest, the foot is a lever of the 1st kind, in which the point of support lies between the points, the application of force and resistance;
• When lifting the toes, the foot acts as a lever of the 2nd kind, in which the point of resistance lies between the points of application of force and support.

The function of the muscles of the foot:

• The plantar flexion in the ankle joint is produced by different muscles, depending on whether the foot is loaded or not.

When the foot is unloaded (ip of the patient is lying on the stomach, the feet are lowered from the edge of the couch), the plantar flexion is produced by mm. Tibialis posterior, peroneus longus, to a lesser extent - m. Peroneus brevis.

ATTENTION! The calf muscle is not reduced.

• The dorsal flexion of the free-hanging foot in the ankle joint is mm. Tibialis anterior, peroneus tertius. Due to the fact that m. Tibialis anterior with contraction suppresses the foot, to obtain an isolated dorsal flexion as a synergist reduces m. Peroneus brevis. A long extensor of the thumb and a common long extensor of the fingers, which also participates in the pronation of the foot, take part in the dorsal flexion.
• Supination - rotation of the foot with the sole inward with simultaneous reduction of the anterior section to the median plane of the body - occurs in the ram-heel-navicular joint. In ip Patient lying on its side, this movement produces only m. Tibialis posterior. But if you add resistance, other instep supports (m. Tibialis anterior and triceps muscles of the lower leg at the same time) come into play, since they must neutralize their action of flexion-extension on the ankle joint and sum up the supination.

ATTENTION! Muscles producing an isolated foot cast, no.

• Pronation - movement, the opposite of supination, is characterized by turning the foot outwardly with simultaneous abduction of the anterior section from the middle plane of the body. Short fibular muscle begins pronation, which produces only abduction of the forefoot. The long fibular muscle produces a turn of the foot outward, abduction and plantar flexion. In addition, a common long extensor of the fingers takes part in pronation of the foot.

[12]

Examination of the function of individual muscles

1. Long extensor thumb.

The muscle function is dorsal flexion of 1 toe and foot.

Muscles are examined in I. P. Patient lying, foot is at right angles to the lower leg. The patient is asked to perform the rear flexion of the thumb (the movement is carried out actively with resistance to the doctor’s arm). With a contraction of the muscle, the tendon easily palpates over the I metatarsal bone.

2. Long extensor fingers.

The muscle function is dorsal flexion of the foot and toes (II-III-IV-V), as well as pronation of the foot.

ATTENTION! The bonus effect is enhanced in the position of the back flexion.

In the study of the muscle strength of the long extensor of the fingers, the patient is asked to set the foot in the position of maximum dorsal flexion with the fingers straightened. In the other case, the doctor with one hand counteracts this movement, and the second one - palpates the tendon of the muscle.

3. Anterior tibial muscle.

The main function of the muscle is dorsal

Flexion in the ankle joint and supination. Muscle also helps to keep the longitudinal arch of the foot.

To determine the functions of this muscle, the foot is installed in the position of a small plantar flexion and abduction, if possible, and suggests the patient to perform dorsal flexion with lifting the inner edge of the foot, the same movement, but the doctor resists movement with the other hand, and palpates the tendon under the skin of the rear foot with the other.

4. Long fibular muscle.

Muscle performs various functions:

• produces plantar flexion of the foot,
• produces pronation (lifting the outer edge of the foot),
• keeps limiting arch of the foot.

The muscle function is determined when the leg is bent at the knee joint, the foot is laid on the surface of the couch with its inner edge. The patient is asked to raise the distal part of the foot above the couch surface (the same movement, but the doctor with one hand resists this movement). The tension of the muscle with the other hand is determined at the head of the fibula.

ATTENTION! Tension of the tendon cannot be determined, since it is within the foot to pass to the plantar surface next to the tendon of the short peroneal muscle.

5. Short fibular muscle.

The function of the muscle - produces plantar flexion, abduction and elevation of the outer edge of the foot.

ATTENTION! The short fibular muscle is the only muscle that gives a clean abduction of the foot.

To determine the function of the muscle, the patient is offered to take the foot outwards (the same movement, but with the doctor’s resistance). Tension of the tendon is determined behind the styloid process of the V metatarsal bone.

6. The triceps muscle of the lower leg is the most powerful muscle of the lower leg. The muscle consists of 3 heads - two superficial and one deep. The two superficial heads form the gastrocnemius muscle, and the deep - soleus.

This muscle is a powerful plantar flexor of the foot. With its tension, it keeps the body upright.

To determine the muscle function of the patient offer:

• in ip standing up toes;
• in ip standing crouch. The doctor measures the distance (in cm) between the heels and the floor;
• in ip - supine, leg bent at the hip and knee joint;
• performing plantar flexion of the foot, while the physician resists movement;
• the patient performs the same movement without resistance.

7. Rear tibial muscle.

Muscle function - produces plantar flexion of the foot and supination. In addition, she is involved in maintaining the longitudinal arch of the foot and prevents the talus from moving to the medial side.

The study of muscle function is carried out with the leg bent at the hip and knee joints, the foot is placed on the surface of the couch with the outer edge. The patient is asked to raise the distal foot, while the doctor provides metered resistance to movement with one hand; with the other hand, he palpates the tendon of the muscle between the inner ankle and the tuberosity of the scaphoid bone (the same movement is performed without resistance).

8. Long finger flexor.

Muscle - produces plantar flexion of the end phalanges of II-V fingers and foot, in addition, it raises the inner edge of the foot.

The study of muscle function produced in the position of the foot at a right angle to the lower leg. The patient is offered to bend the fingers, the doctor has resistance to movement with one hand, and the other with the palpable tendon of the muscle behind the inner ankle (the same movement, but without resistance).

9. Long flexor thumb.

The function of the muscle - produces plantar flexion of the first finger, raises the inner edge of the foot.

The study of muscle function produced in the position of the foot at a right angle to the lower leg. The patient is offered to bend the thumb, the doctor resists the movement with the hand, the other - palpates the tendon located behind the inner ankle (the same movement, but without resistance).

Thus, having determined the function of each muscle separately, the doctor has a complete picture of the state of the muscles of the leg.

[13], [14], [15]

Thigh muscles

A. In the bend of the thigh take part:

• ilio-lumbar muscle;
• rectus femoris;
• sartorius;
• scalloping muscle;
• a muscle that tightens the wide fascia of the thigh.

To determine the function of the muscles involved in flexing the thigh, the patient is asked to bend the leg in the hip and knee joints. When performing this movement, the following research options are possible:

• the doctor holds the patient's lower leg with one hand (in the lower third of the calf or heel)! The other is palpating straining muscles;
• the doctor with one hand prevents hip flexion;
• the patient is actively bending the leg in the hip and knee joints.

The anterior thigh muscle group includes the quadriceps muscle of the thigh, which has four heads:

• straight muscle of the thigh;
• wide lateral;
• wide intermediate;
• wide medial muscle.

The broad muscles of the thigh begin from the anterior, lateral, and partially the posterior surface of the femur. In the lower third of the thigh, all four heads are combined into a common tendon that attaches to the tibial tuberosity.

In the thickness of the tendon is patellar cup.

Muscle function:

• unbends a shin;
• rectus flexes the hip.

The study of the functional state of the muscle is carried out in the initial position of the patient - lying on his back:

• active movement - extension of the leg;
• movement with the resistance of the hands of the doctor.

ATTENTION! In the presence of shortening of the posterior group of thigh muscles, it is impossible to carry out a full reduction of the four-headed muscle. When a shortening of the muscle straining the fasciae is detected, dissociation of the medial part of the quadriceps is observed.

B. In the extension of the thigh take part:

• gluteus maximus muscle;
• biceps muscle of thigh;
• semi-membranous muscle;
• semitendinosus muscle.

The contraction of the posterior thigh muscle group occurs:

• when torso forward;
• giperlordoze;
• spondylolisthesis, when the back edge of the pelvis rises and, therefore, the ischial tubercle, from where these muscles originate.

As a result of compression of the fibers of the peroneal nerve (when it is still in the sciatic nerve) with the biceps muscle, a tunnel syndrome of its defeat can occur with symptoms of prolapse up to paresis of the foot. The same role can be played by semi-tumbler and semi-membranous muscles. This is especially true of people whose work requires squatting, kneeling.

Studies of the functional state of the muscles are carried out in I. P. Patient lying on his stomach. When muscles are weakened, the patient is unable to raise the leg above the horizontal level. Normally, according to I. Dyurianova, the patient should raise it by 10-15 ° above the horizontal level. An isolated study of the gluteus muscle group is carried out with the leg bent at the knee joint (to prevent replacement stresses in the posterior group of the thigh muscles).

The same movements may be carried out with metered resistance (with the hand of a doctor).

B. The following are involved in the cast of the thigh:

• large adductor muscle;
• long and short adductor muscles;
• scalloping muscle;
• tender muscle.

The study leading thigh muscles is carried out in the initial position of the patient lying on his back and sitting.

1. The function of the short adductors of the thigh is checked when the leg is bent at the hip and knee joints.
2. The function of the long adductor muscles is advisable to determine with straightened legs.

The test movement is performed with the resistance of the hands of the doctor. When you try to bring the leg to the patient may experience pain. In these cases, it is recommended to determine by palpation the myalgic zone. According to K.Levit (1993), the myalgic zone with a lesion of the sacroiliac joint is located at the site of attachment of the adductor muscles of the thigh, on its medial surface, and during coxalgia - at the edge of the acetabulum in the ileal-femoral ligament.

G. In the hip abduction take part:

• gluteus medius muscle;
• small gluteus maximus muscle.

The study is conducted in the initial position of the patient lying on his back and sitting. The test movement is performed with the resistance of the hands of the doctor.

D. The rotation of the thigh inward exercise the following muscles:

• anterior bundles of the middle gluteus muscle;
• anterior bundles of small gluteus maximus muscle.

The study of the muscles is carried out in I. P. Patient lying on his back. The test movement is performed with the resistance of the hands of the doctor.

E. The rotation of the thigh outward exercise the following muscles:

• gluteus maximus muscle;
• back portions of the middle and small gluteus muscles;
• sartorius;
• internal and external obturator muscles;
• square muscle of the thigh;
• pear-shaped muscle.

The study of the functional state of the muscles is carried out in I. P. Patient lying on his back. The test movement is performed with the resistance of the hands of the doctor.

Pelvic muscles

In the pelvic area there are internal and external muscles.

A. Internal muscles of the pelvis.

1. Ilio-psoas muscle.

Function:

• bends the hip and rotates it outward;
• with a fixed lower limb tilts the pelvis and torso forward (flexion).

The study of the functional state of the muscle is carried out in I. P. Patient supine:

• active movements of the legs bent at the hip and knee joint. The same movement is performed with the resistance of the doctor's arm;
• active movements - bending of the thigh, performed with straight legs (alternately and simultaneously). The same movement is performed with the resistance of the doctor's hand.
• active movements - with fixed lower limbs - torso forward. The same movement is performed with the resistance of the hands of the doctor or with the burden.

2. Pear-shaped muscle.
3. Internal locking muscle.

Function: rotate the thigh outward.

B. The external muscles of the pelvis.

1. Big gluteus muscle.

Muscle function:

• extends the thigh, rotates it out;
• with fixed limbs unbends the body.

To study the function of the gluteus maximus muscle is necessary from the initial position of the patient lying on his stomach:

• bend the leg at the knee;
• with fixed legs, straighten the torso.

The same movements are performed with the resistance of the hands of the doctor.

2. The gluteus maximus muscle.

Muscle function:

• removes the thigh;
• front beams rotate the thigh inward;
• back bunches rotate a hip outside.

3. Small gluteus maximus muscle.

Muscle function is similar to the average gluteus.

The study of the functional state of the middle and small gluteus muscles is carried out in the initial position of the patient lying on its side. The patient is asked to take a straight leg to the side. Normal leg abduction is 45 °. Movement can be performed with the resistance of the hands of the doctor.

ATTENTION! If during the abduction of a straight leg, the rotation of the foot is detected outside, this indicates the tension of the muscle fibers of the middle and small gluteal muscles.

4. Muscle straining wide fascia.

Function - strains the wide fascia.

5. Square thigh muscle.

Function - rotates the thigh outward.

6. External locking muscle.

Function - rotates the thigh outward. Another component of the vertebral syndrome is reflex tension of the paravertebral muscles, aimed at limiting movements in the affected segment of the spine.

The contracture is clearly visible during a simple inspection, often it is asymmetric and more pronounced on the affected side. When the spine moves, especially when trying to flex the trunk, muscle contracture increases and becomes more noticeable.

[16], [17]

Investigation of the paravertebral muscles

A. Superficial paravertebral muscles:

• in ip patient standing. If the muscle that straightens the spine is affected, it can bend the torso only a few degrees.

ATTENTION! In this position, palpation of the corresponding muscles is ineffective due to postural muscle tension and the protective connection of healthy muscles.

• For better relaxation of the patient's muscles, one should lay on the side with the legs brought to the chest. This position contributes to more efficient palpation of the muscles.

B. Deep paravertebral muscles:

• in ip while standing the patient is not able to freely perform the torso of the torso to the sides, rotation and extension of the torso;
• with the flexion of the body between the spinous processes, it is possible to identify a depression or flattening;
• affection of partitioned muscles or rotator muscles is accompanied by pain in the region of the adjacent spinous processes.

ATTENTION! The direction of palpation is to the body of the vertebra, where the greatest tenderness is localized.

[18], [19], [20]

Method of study of the abdominal muscles

Abdominal TTs usually develop in muscles prone to acute or chronic overstretching, or in muscles that are in the area of pain reflected from internal organs.

ATTENTION! The tension of the abdominal muscles allows you to distinguish myofascial pain from visceral.

Long trial :

• ip patient - supine, legs straight;
• the patient lifts straight legs from the couch; The doctor palpates the tense muscles. If the pain does not melt during this movement, this indicates its muscular origin; if the pain decreases, then you can judge its visceral genesis.

Abdominal rectus muscle research:

• ip patient - supine, legs bent at the knee and hip joints, hands behind the head; on command, the patient should sit down slowly, without jerks;
• at the doctor's command, the patient slowly straightening his legs, lifts his head and shoulders and holds them for 5-7 seconds.

Examination of the internal and external oblique abdominal muscles:

• ip patient - supine, legs bent at the knee and hip joints, hands behind the head;
• at the command of the doctor, the patient slowly lifts the body (up to a 45 ° angle) and rotates it somewhat (30 °). It compares the functioning of the oblique abdominal muscles with the affected and healthy sides (J.Durianova).

Study of range of motion

A. Study of active movements:

• bending forward in patients is usually limited — the back remains flat, does not take the form of an arc, and the bend itself is due to flexion in the hip joints and to a small extent due to the thoracic spine.

ATTENTION! In a number of patients, the forward torso is possible only by 5-10 ° and further attempts cause increased pain.

• tilt back in 90% of patients is limited (the compensatory and protective role of flattening lordosis and kyphosis) - the more straightened lordosis, the smaller the degree of back extension.

ATTENTION! In a functional unit, patients try to carry out extension through the thoracic and even the cervical spine, while bending the legs at the knee joints, which outwardly creates the illusion of this movement.

• side slopes are most often limited and depend on:

A) the type of scoliosis of the spine. A typical picture is a sharp or even complete block of movements in the direction of the convexity of the curvature with a satisfactory preservation of movements in the opposite direction.

ATTENTION! This mechanism depends entirely on the relationship of the spine to the disc herniation, since any movement towards the bulge of scoliosis leads to an increase in the tension of the spine.

B) the functional block PDS (L ₃ -L4) - a limited range of movements is carried out due to the overlying segments of the spine.

• rotational movements do not significantly suffer and decrease by 5–15 ° (rotation of the body with fixed legs at 90 ° is considered normal).

B. Study of passive movements.

The anatomical features of the structure of intervertebral joints determine the relatively high mobility of this section in the sagittal plane, much smaller in the frontal and minor (except for the lumbosacral articulation) in the horizontal /

Tilt to the side:

• ip patient - lying on its side with legs bent at a right angle (in the knee and hip joints);
• the doctor, grabbing the patient's ankles with his hands, lifts the legs and pelvis of it, while making a passive lateral tilt in the lumbar segments.

Extension:

• ip patient - lying on its side with legs bent;
• with one hand, the doctor slowly and smoothly unbends the patient's legs, controlling this movement in each segment with the index finger of the other hand located between the spinous processes.

Flexion:

• ip patient - lying on its side, legs bent;
• with the help of his knee, the doctor slowly and smoothly bends the patient's torso, controlling the movement in each segment with his hands located on the spine.

Rotation:

• ip patient - sitting or lying down;
• the doctor places his fingers on 2-3 spinous processes of the adjacent vertebrae, sequentially moving in the cranial direction.

ATTENTION! Due to the fact that the rotation in the L4-5 segments is insignificant, only the study of the displacement of the spinous process of L5 with respect to S1 is of diagnostic importance.

Direct palpation of pelvic girdle formations is possible in relatively limited areas. Bone base of the pelvis is located deep in the thickness of the soft tissues and in some cases direct palpation is not available. As a consequence, direct palpation of the pelvis in most cases makes it possible only partially to determine the localization of the lesion. The defeat of the deep parts of the pelvis is determined by the following methods:

1. symptom of transverse concentric compression of the pelvis. The doctor puts his hands on the side surfaces of the patient's pelvis (i.e., lying on his back), fixing the crests of the iliac bones and then squeezes the pelvis in the transverse direction. Pain occurs in the affected area.
2. symptom of transverse eccentric compression of the pelvis:

• ip patient - supine;
• the doctor, grasping the crests of the iliac bones (near the front upper spines), makes an attempt to “open up” (move apart) the edges of the pelvis, pulling the front sections of the crests from the midline of the body. With the defeat there is pain.

3. The symptom of the vertical pressure of the doctor’s hands in the direction from the tubercle of the ischium (2) to the iliac crest (I) complements the data on the localization of the deeply located lesion of the pelvic bones.

When the axis of the pelvic girdle is displaced due to a disease of the spine, lower extremities, joint deformities, it is recommended to determine the amount of displacement of the pelvic wings by the distance of the anterior upper ileal bones from the midline of the body (possibly from the end of the xiphoid process of the sternum) to the anterior upper spine of the pelvis in front and from the spinous process of one of the vertebrae to the posterior superior spines (with dislocations, subluxation of the ilium in the sacroiliac joint).

ATTENTION! In cases of lesions of the sacroiliac joint during the differentiated techniques, any movements in the lumbar spine should be avoided, which can mimic the appearance of mobility in the joint and as a result - the occurrence of pain.

These techniques include the following:

1. Reception V.V. Kerniga. The patient is in I. P. Lying on your back. The doctor puts one arm under his back in the lower lumbar vertebrae. This hand is necessary to palpate the spinous processes of the L5 and S1 vertebrae. With the other hand, the doctor, seizing the patient’s straight leg, slowly bends it at the hip joint. In order to establish which of the joints is affected - the sacroiliac or lumbosacral, it is important to accurately determine the time of the onset of pain. If the pain appears before the lumbar vertebra movements occur (they are felt by the doctor’s hand under the patient’s back), this indicates a disease of the sacroiliac joint; if the pain appears from the moment the spinal movements occur, this indicates a lumbosacral joint disease.

ATTENTION! During the reception should be remembered that at first there is a movement in the sacroiliac joint. The study is conducted on both sides.

The occurrence of pain in patients during this technique is explained by insignificant movements in the sacroiliac and lumbar joints, which are manifested due to the traction of the muscles attached to the sciatic tubercle (mm. Biceps femoris, semitendinosus et semimembranosus).

2. Acceptance of pressure on the pubic joint. The initial position of the patient is lying on his back. When performing this technique, the movement in the sacroiliac joint is possible, and as a response, pain on the affected side can occur.
3. Receiving over-leg extension. The symptom is based on pain in the region of the sacroiliac joint caused by passive movement in the examined joint. It is checked on both sides. The patient is placed on the edge of the table so that the leg on the side of the studied joint hangs loose. The other leg is bent with the patient's hands and pulled toward the abdomen in order to fix the pelvis. The doctor gently perestaglya freely hanging thigh, gradually increasing its effort. Over-bending leads to rotational motion in the sacroiliac joint due to the ileal-femoral ligament and muscles attached to the front (upper and lower) iliac spine. As a result of movements, local radiating pains occur in the studied joint.
4. Campbell's symptom. The patient is sitting in a chair. With the defeat of the sacroiliac joint when the body is bent forward, the pelvis remains in a state of fixation and pain does not occur. With the extension of the trunk, pain appears in the region of the affected joint.
5. Knee-heel test (reception of hip abduction). The initial position of the patient is lying on his back, the pelvis is fixed by the doctor’s hand. Extreme abduction of the hip, bent at the hip and knee joints and rotated outwards (the heel touches the hip of the straightened other leg), causes pain in the same sacroiliac joint and limits the amplitude of the movement of the hip. In this case, measure the distance (in cm) between the knee and the couch and compare the result with those from the other side. Normally, the knee of the bent leg should lie on the surface of the couch.

This symptom checks flexion (flexio), abduction (abductio), external rotation (rotatio) and extension (extensio). It is also called the Faber sign by the initial letters of each movement. In later editions, this symptom is called the Patrick phenomenon.

The indicative tests of the study of the sacroiliac joint, based on the occurrence of pain in the articulation with certain movements, include the following:

• the appearance of pain at the moment when the patient quickly sits down (test Larrey);
• the appearance of pain when rising on a chair at the beginning of a healthy and then sore foot and when the patient is sinking from a chair, and then of a healthy leg (Ferguson’s test);
• the appearance of pain in the situation - one leg is located on the other; the patient is sitting in a chair (Soobrazha test);
• soreness with hand pressure on the median sacral crest; patient's position - lying on his stomach (Volkmann-Ernesen test);
• soreness when turning the thigh inward with the leg bent at the knee joint; the patient's position is supine (test Bonn);
• pain in the ileo-sacral articulation, caused by irritation of the nerve roots of the lumbar spine, allows us to differentiate the Steindler's test of piercing with a solution of novocaine of the most painful area in the lumbar spine does not relieve pain in the iliac sacral articulation.

[21], [22]

Static Violations

A. The flattening of the lumbar lordosis is one of the compensatory mechanisms that reduce the volume of the hernial disc protrusion, which in turn reduces compression on the posterior longitudinal ligament and adjacent root.

ATTENTION! Changes in statics in the form of flattening or disappearance of lumbar lordosis in osteochondrosis of the spine is a protective installation of the torso.

B. Lumbar kyphosis. The protective mechanism of the fixed kyphosis consists in stretching the posterior fibrous semiring, which has lost its elasticity and elasticity.

ATTENTION! In the kyphosed state of the lumbar spine, the prolapse of fibrous ring fragments together with the pulpal nucleus into the lumen of the spinal canal decreases, leading to a decrease or cessation of neurological disorders for a certain time.

B. Hyperlordosis arises as a protective-compensatory reaction of the body in response to the forward shift of the center of gravity of the body (for example, in pregnancy, in obesity, in flexion contracture of the hip joint, etc.).

When hyperlordosis decreases the diameter of the intervertebral foramen, the pressure on the posterior parts of the intervertebral disk increases, an overstretching of the anterior longitudinal ligament occurs, squeezing of the interspinal ligaments between the approaching spinous processes, the overstretching of the capsules of the intervertebral joints. The extension is difficult because it contributes to the reduction of the intervertebral space.

G. Scoliotic spinal implantation is caused by the reflex reaction of the muscular system, which gives the spine a position that contributes to the displacement of the spine from the maximum size of the hernial disc bulging to the side (right or left), and the degree of tension of the spine decreases and the flow of pain impulses is limited.

ATTENTION! The side of scoliosis will depend both on the localization of the hernia (lateral or paramedial), its size, mobility of the root, and on the structural features of the spinal canal and the nature of the reserve spaces.

• In homolateral scoliosis, the root is laterally displaced and often tightly pressed against the inner surface of the yellow ligament. Hernia localization is paramedial.
• In heterolateral scoliosis, the reverse relationship is observed - the disc hernia is located more laterally, and the root tends to shift medially.

In addition to static disorders in patients, the biomechanics of the spine also suffers substantially, mainly due to the mobility of the lumbar spine.

• The forward bending of the body is usually limited, while the back remains flat, does not take the form of an arc, as is normal, and the bend itself is due to flexion in the hip joints and to a small extent due to the thoracic spine. In a number of patients, the forward torso is possible only by 5-10, and further attempts cause a sharp increase in pain. Only patients with a developed kyphosis of the lumbar spine can usually bend forward in full.
• The slope of the torso of the posterior is often the restriction more straightened lordosis, the lower the degree of extension back. The complete lack of movement of the lumbar spine in one direction or another is called a "block". During the blockade of the lumbar movements backwards, patients are trying to carry out extension due to the thoracic and even cervical spine, while bending the legs at the knee joints, which outwardly creates the illusion of this movement.
• The volume of body movements to the sides is usually disturbed , which depends on the type of scoliosis. A typical picture is a sharp limitation or even a complete block of movements in the direction of the convexity of scoliosis with a satisfactory preservation of movements in the opposite direction. This mechanism depends on the relationship of the spine to the disc herniation, since any movement towards the bulge of scoliosis leads to an increase in the tension of the spine. Along with this, it is often necessary to observe a blockade of movements in the lumbar region in both directions, while the III-V, and sometimes the II lumbar vertebrae are completely excluded from the movements. The limited range of motion is due to the overlying spinal segments. A number of patients experience blockade of all types of movement in the lumbar region, which is caused by a reflex contraction of all muscle groups that immobilize the affected spine in the most advantageous position.
• The rotational movements of the spine do not significantly suffer and decrease by 5–15 ° (rotation of the body with fixed legs at 90 ° is considered normal).

The lumbosacral junction and the pelvis The bones of the pelvic girdle are connected to each other in front of the pubic semi-articular joint, and behind them form the sacroiliac joints with the sacrum. The result is a pelvis.

The sacroiliac joint is formed by the luminal surfaces of the sacrum and the ilium and is a flat joint. The articular capsule is anterior and posteriorly supported by strong short ligaments. The sacroiliac interosseous ligament, stretched between the iliac tuberosity and the tuberosity of the sacrum, plays an important role in strengthening the joint.

The pubic half-joint (pubic union) is formed by the pubic (pubic) bones, which are firmly adhered to the fibro-cartilaginous inter-focal disk located between them. In the thickness of the disk has a slit-like cavity. From above, the pubic fusion is reinforced by the upper pubic ligament, and from the bottom - by the arcuate pubic ligament.

The pelvis normally represents a closed ring with sedentary links. The position and inclination of the pelvis depend on the position of the lumbar spine, the state of the hip joints and abdominal muscles, as well as the muscles locking the lower opening of the pelvis. There is a direct correlation of the pelvis and the position of the lower limbs. With congenital dislocation, coxitis, ankylosis, contracture in the hip joint, the position of the pelvis changes markedly. The mutually movable parts of the pelvis are the iliac bones and the sacrum on the one hand, and the pubic bone on the other. There is an articulation (art. Sacroilia) between the iliac bone and the sacrum, which in an imperceptible manner complements the movement in the iliac sacral articulation and in the hip joint.

For the vertical position of the body in space, the pelvis should be placed strictly horizontally. With an asymmetrical location of the pelvis, the normal functioning of the vestibomulozdzhechkovoy, striopallidarnoy and antigravitational systems of the human body is hampered.

A change in the spinal column (scoliotic installation) leads to a defect in posture, incorrect positioning of the legs. These distorted biomechanical effects are transmitted through the pelvic joints, which can be a source of pseudo-root pain, radiating to the inguinal region, the buttock, the shin, along the posterior lateral surface of the thigh. According to Klevit (1993), pain from the sacroiliac joint never radiates to the midline of the body. This is an important hallmark of pain in the sacroiliac joint.

When visual inspection should pay attention to:

• possible distortion of Michaelis sacral rhombus;
• asymmetry of the gluteal folds;
• possible displacement of one buttock down;
• asymmetry of the pelvic girdle line.

Mandatory palpation:

• iliac crest;
• spinous processes;
• knob.

[23], [24]