**4. Physical examination**

The physical evaluation aims at the differential diagnosis of the condition as well as to identify the nerve root(s) involved. The findings depend on the severity of the condition and if there are signs of neurological involvement. In the presence of neurological claudication, patients generally walk with an antalgic gait (gait to avoid or reduce pain), with the trunk listing forward to widen the spinal canal and to reduce the compression on the nerve roots. In more severe cases, the patients may walk with flexed hips and knees [48]. With progression of the condition, the walking distance reduces. Not uncommonly, the patient reports a reduction in height, which averages 4–24 cm. in 1–22 years [49].

Inspection from the back generally shows a hump in the low back with the concavity on the opposite side. Generally pelvic obliquity occurs; Radcliff et al. [50] reported a pelvic tilt in 87% of patients with DLS [50, 51]. Patients with a single lumbar curve were more likely to have a higher pelvis contralaterally (79%), as a compensatory mechanism to maintain coronal trunk balance [50]. Patients with a lumbar curve and a compensatory lumbosacral hemicurve did not display consistent pelvic obliquity compensatory patterns [50].

In the presence of marked pelvic obliquity or pelvic tilt, apparent leg length discrepancy becomes evident, with the leg ipsilateral to the lumbar convexity appearing shorter [50] and the posterior superior iliac spines being unlevel. The coronal spinal imbalance can be determined by measuring the distance from C7

### **Figure 7.**

*Coronal imbalance and sagittal imbalance are evident in this man aged 62 years old. He complained of radiculopathy localized to the right anterior thigh. The radiograph (a) showed a right lumbar scoliosis with a mild compensatory left thoracolumbar scoliosis. Though the sagittal imbalance was not significant (b), there was a reduction in sacral slope and thoracolumbar lordosis.*

to the vertical line extended from the gluteal cleft. The distance measured in mm. represents the coronal shift (**Figure 7**). In the presence of a single thoracolumbar or lumbar curve, the spine is generally decompensated to the side of lumbar convexity.

In patient with DLS, sagittal imbalance is more significant clinically than coronal imbalance [52]. Loss of lumbar lordosis is generally evident with patients leaning forward [48]. In cases with spinal stenosis, patients may flex their hips and knees to compensate for the sagittal spinal imbalance. In long standing cases, contracture of the hips may result, which can be assessed by the Thomas leg raise test [53].

The physical examination can also be used to identify the pain driver. Tenderness is generally elicited at the junction between two major curves, including the junction between the thoracic and lumbar curves and between the lumbar curve and the compensatory lumbosacral hemicurve. Also, pain can be elicited at the apex of the thoracolumbar or lumbar curves [33] and on the iliac crest where the tendons of the lumbar paraspinal muscles attach [1]. A neurological examination which consists of the assessment of motor strength, reflexes, sensation, and gait also needs to be performed, to assess the extent of neurological involvement and to rule out other possible causes of back pain.
