1-20 Low Back Pain & Herniated Nucleus Pulposus Flashcards
What is the lifetime prevalence of LBP?
70%
What is the cost of LBP, in terms of physician visits and surgical procedures?
2nd most common reason for physician visits
3rd most common reason for surgical procedures
What is the total cost ($) of LBP in the US?
> $100 billion
What are the quality of life costs of LBP?
72% gave up on exercising or sport
46% gave up on sex
What should be first taken into account when creating a DDx for LBP?
Localized or diffuse
If local, is it mechanical?
If mechanical, is there radiation below the knee?
What 6 things should be considered for a DDx for localized LBP, mechanical, without radiation below the knee?
Non-specific muscular and/or ligamentous injury
Somatic dysfunction
Degenerative disc disease
Degenerative joint disease
Spondylolithesis
Fracture/spondylolysis
What 3 things should be considered for a DDx for localized LBP, mechanical, WITH radiation below the knee?
Cauda Equina Syndrome
Radiculopathy
Spinal stenosis
What should be considered for localized LBP without a mechanical cause?
Infection
- osteomyelitis
- discitis
Neoplasm
- primary (osteosarcoma, osteoidosteoma)
- metastatic (breast, lung, thyroid, kidney, prostate)
- multiple myeloma
Inflammation
- spondyloarthropathy
- Rheumatoid arthritis
What should be considered for a referred LBP?
GI Disease
- IBD
- Diverticulitis
- Pancreatitis
Renal Disease
- Nephrolithiasis
- Pyelonephritis
Gynecological problems
- Endometriosis
- Menstrual cramps
Vascular
- Abdominal aortic aneurysm
Psychological
- Somatoform disorder
- Malingering
- Central sensitization/chronic pain syndrome
What can relief of LBP with complete immobility tell you?
It might be due to:
- acute infection
- compression - suspect metabolic bone disease
- pathological fracture - suspect tumor or infiltrative disease
What can aggravation of LBP with prolonged sitting or leaning forward tell you?
Might be due to:
- herniated disc
What can aggravation of LBP with prolonged standing and extension tell you?
Might be due to:
- spinal stenosis
“shopping cart sign”
What can lack of relief of LBP in any position tell you?
Might be:
- psychogenic pain
What are some symptoms of psychogenic LBP?
Not well localized, follows no pattern, constant, and patients cannot describe alleviating or aggravating factors.
What is shopping cart sign?
Shopping cart sign: pain relieved when leaning forward onto a shopping cart; forward bending causes spinal canal and foramina to open which relieves pressure
What are 2 clues that you need to consider with radiating pain?
Radiating pain with extension
- stenosis
Radiating pain at rest
- Disc herniation
What should be considered with stiffness and pain upon walking?
Inflammatory arthropathies
What does intense night time pain indicate?
bone tumors
What are 6 red flags that should be considered before treating LBP?
Bowel or bladder dysfunction
Saddle anesthesia
B/L weakness or numbness in legs
Acute neuro deficits in patients with cancer
- BLT with a Kosher Pickle
Progressive or severe neuro deficit
LBP along with fever in a patient who uses IV drugs
Why should you consider red flags before treatment?
- I would not treat these patients until these sx have been immediately investigated. Law suit territory.
What is a yellow flag? How would you proceed?
Positive straight leg raise test
I may treat GENTLY during the first visit that they exhibit these findings, but I wouldn’t have them back for another treatment until this is investigated.
What is a straight leg raise test?
Straight leg raising is done with the patient supine. The examiner raises the patient’s extended leg with the ankle dorsiflexed, being careful that the patient is not actively “helping” in lifting the leg. The test is considered positive when the sciatica is reproduced between 10 and 60 degrees of elevation.
What is the crossed straight leg test?
The crossed straight leg raising test refers to elevation of the unaffected leg. The test is positive when lifting the unaffected leg reproduces the sciatica in the affected leg.
What is the seated straight leg test?
The seated straight leg test is done while the patient is in the seated position and the lower leg is slowly extended until the leg is flexed at the hip to 90 degrees. If sciatica is present, the pain will be reproduced as the leg is extended.
What does a positive straight leg test have limited sensitivity for?
has limited sensitivity and specificity for herniated disc (64 and 57 percent respectively)
What is the crossed straight leg test sensitive for? Specific?
[53]. The crossed straight leg test is less sensitive for herniated disks, but is 90 percent specific.”
Case 1:
A 54 yo male presents with low back pain x 1 month. He describes the pain as a dull ache that is worse at the end of the day. He works as a therapist and sits at a desk for most of the day.
What else do we want to know?
No radiation
No weakness or numbness
No change in bowel or bladder function
PMH noncontributory
What should be considered in cases of LBP with shoulder pain?
Latissimus dorsi
Originates in the thoracolumbar fascia, iliac crest and spinous processes of lower 6 thoracic vertebrae and inserts on the intertubercular groove of the humerus
Functionally connects the lumbar, thoracic, and pelvic regions to the upper extremity
What is the origin of the quadratus lumborum?
Origin is the iliolumbar ligament and iliac crest; inserts on the tips of the L1-4 transverse processes and the anterior surface of the 12th rib
What is the QL considered a part of, functionally?
Functionally considered a posterior inferior extension of the abdominal diaphragm
