10- low back pain

Question 1

most low back pain clears up in how long

Answer 1

2-4 weeks

Question 2

What are the three most common causes of back pain?

Answer 2

lumbar strain- 70%
disc herniation
degenerative joint disease

Question 3

Acute sciatica

Answer 3

lower back pain with radiculopathy below the knee and symptoms lasting up to six weeks.

causes: disk herniation, lumbar spinal stenosis, facet joint osteoarthritis or other arthropathies, spinal cord infection or tumor, or spondylolisthesis.

Question 4

Risk Factors for Low Back Pain

Answer 4

Prolonged sitting, with truck driving having the highest rate of LBP, followed by desk jobs
Deconditioning
Sub-optimal lifting and carrying habits
Repetitive bending and lifting
Spondylolysis, disc-space narrowing, spinal instability, and spina bifida occulta
Obesity
Education status: low education is associated with prolonged illness
Psycho-social factors: anxiety, depression stressors in life
Occupation: Job dissatisfaction, increased manual demands, and compensation claims

Question 5

Red Flags For Serious Illness or Neurologic Impairment with Back Pain

Answer 5

Fever
Unexplained weight loss
Pain at night
Bowel or bladder incontinence
Neurologic symptoms
Saddle anesthesia

Question 6

Pain worse with movement and sitting is suggestive of

Answer 6

a mechanical cause of back pain, such as a lumbar strain, disc herniation,or degenerative arthritis.

Question 7

Pain radiating down the leg and numbness indicate

Answer 7

nerve involvement, such as in disc herniation.

Question 8

Pain that improves with the supine position suggests

Answer 8

spinal stenosis and disc herniation.

Question 9

Cauda equina syndrome

Answer 9

large mass effect (such as an acute disc herniation or a tumor) compresses the cauda equina, causing pain radiating down the leg and can be accompanied by weakness and numbness of the leg.

EMERGENCY- Decompression should be performed within 72 hours

Question 10

Ankylosing spondylitis

Answer 10

Chronic, painful, inflammatory arthritis primarily affecting the spine and sacroiliac joints, causing eventual fusion of the spine.

Often seen in patients 15-40 years old, associated with morning stiffness and achiness over the sacroiliac joint and lumbar spine.

Question 11

back pain presentation in context of malignancy

Answer 11

localized to the affected bones, it is a dull, throbbing pain that progresses slowly, and it increases with recumbency or cough.

> 50 yo

Question 12

Spondylolisthesis

Answer 12

Anterior displacement of a vertebra or the vertebral column in relation to the vertebrae below.

Can occur at any age.

Causes aching back and posterior thigh discomfort that increases with activity or bending.

Question 13

which GI disorders can cause back pain

Answer 13

pancreatitis
cholecystitis
ulcers

Question 14

Restriction and pain during flexion are suggestive of

Answer 14

herniation, osteoarthritis, or muscle spasm.

Question 15

Pain with extension is suggestive of

Answer 15

degenerative disease or spinal stenosis.

Question 16

pain with lateral motion indicates

Answer 16

pain on the same side as bending= bone pathology, such as osteoarthritis or neural compression.

Pain on the opposite side of bending: muscle strain.

Question 17

Difficulty with heel walk is associated with

Answer 17

L5 disc herniation

Question 18

Difficulty with toe walk is associated with

Answer 18

S1 disc herniation

Question 19

squatting will reduce the pain in what disease

Answer 19

central spinal stenosis

Question 20

muscle strength rating scale

Answer 20

0/5 No movement
1/5 Barest flicker of movement of the muscle, though not enough to move the structure to which it’s attached.
2/5 Voluntary movement, which is not sufficient to overcome the force of gravity.
3/5 Voluntary movement capable of overcoming gravity, but not any applied resistance.
4/5 Voluntary movement capable of overcoming “some” resistance
5/5 Normal strength

Question 21

L3
Reflex
Pin-Prick Sensation
Motor Examination
Functional Test

Answer 21

Reflex: Patellar tendon reflex
Pin-Prick Sensation: Lateral thigh and medial femoral condyle
Motor Examination: Extend quadriceps
Functional Test: Squat down and rise

Question 22

L4
Reflex
Pin-Prick Sensation
Motor Examination
Functional Test

Answer 22

Reflex: Patellar tendon reflex
Pin-Prick Sensation: Medial leg and medial ankle
Motor Examination: Dorsiflex ankle
Functional Test: walk on heels

Question 23

L5
Reflex
Pin-Prick Sensation
Motor Examination
Functional Test

Answer 23

Reflex: Medial hamstring
Pin-Prick Sensation: Lateral leg and dorsum of foot
Motor Examination: Dorsiflex great toe
Functional Test: Walk on heels

Question 24

S1
Reflex
Pin-Prick Sensation
Motor Examination
Functional Test

Answer 24

Reflex: achilles tendon reflex
Pin-Prick Sensation: Posterior calf, Sole of foot, and lateral ankle
Motor Examination: Stand on toes
Functional Test: Walk on toes

Question 25

what is indicative of “tripod sign” in straight leg test? ( leaning backward and supporting himself with his outstretched arms on the exam table.)

Answer 25

structural disease

test is positive if pain radiates down the posterior/lateral thigh past the knee. This radiation indicates stretching of the nerve roots (specifically S1 or L5) over a herniated disc.

Question 26

muscle tests to do in supine

Answer 26

abdominal: auscultate (aneuryms) and palpate for tenderness

Passive Straight Leg Raise

cross leg raise test

FABER

muscle atrophy

Question 27

Passive Straight Leg Raise normal degree

Answer 27

80 degree

Question 28

To differentiate between tight hamstrings and a sciatic nerve problem in straight leg test

Answer 28

raise the leg to the point of pain, lower slightly, then dorsiflex the foot. If there is no pain with dorsiflexion, the patient’s hamstrings are tight.

Question 29

what does it mean when theres pain less than 30 degrees in straight leg test?

Answer 29

malingering! no disc herniation

Question 30

Crossed Leg Raise

Answer 30

asymptomatic leg is raised

Test is positive if pain is increased in the contralateral leg; this correlates with the degree of disc herniation. Such results imply a large central herniation.

Cross SLR test is much less sensitive (0.25) but is highly specific (about 0.90). Thus, a negative test is nonspecific, but a positive test is virtually diagnostic of disc herniation.

Question 31

FABER Test:

Answer 31

Flexion, Abduction, and External Rotation

looks for pathology of the hip joint or sacrum

flexing the hip and placing the foot of the tested leg on the opposite knee. Pressure is then placed on the tested knee while stabilizing the opposite hip.

The test is positive if there is pain at the hip or sacral joint or if the leg cannot lower to the point of being parallel to the opposite leg from pathology of the hip, sacrum or sacroiliac joint.

Question 32

hints of history it’s disc herniation

Answer 32

exacerbation when sitting or bending; and relief while lying or standing.

increased pain with coughing and sneezing
pain radiating down the leg and sometimes the foot
paresthesias
muscle weakness, such as foot drop

Question 33

Urinary retention is part of which back disorder

Answer 33

cauda equina syn

Question 34

how is disc herniation resolved?

Answer 34

typically self-limited and usually resolves in two to four weeks,

Question 35

what are other red flags for caua equina syn

Answer 35

urinary retention
Saddle anesthesia
Anal sphincter tone decreased or fecal incontinence
Bilateral lower extremity weakness or numbness
Progressive neurologic deficits

Question 36

Significant Herniated Nucleus Pulposus hints

Answer 36

Major muscle weakness (strength 3 of 5 or less)

Foot drop

Question 37

red flags for vertebral fracture

Answer 37

Prolonged use of corticosteroids
Mild trauma over age 50 years
Age greater than 70 years
History of osteoporosis
Recent significant trauma at any age 
Previous vertebral fracture

Question 38

red flags for infection

Answer 38

Persistent fever (temperature over 100.4 F)
History of intravenous drug abuse
Recent bacterial infection, particularly bacteremia (UTI, cellulitis, pneumonia)
Immunocompromised states (chronic steroid use, diabetes, HIV)

Question 39

red flags for cancer

Answer 39

History of cancer
Unexplained weight loss >10 kg within 6 months
Age over 50 years or under 17 years old
Failure to improve with therapy
Pain persists for more than 4 to 6 weeks
Night pain or pain at rest

Question 40

when should CBC and ESR be ordered?

Answer 40

if tumor or infection is suspected.

Question 41

indications for x ray

Answer 41

History of trauma
Strenuous lifting in patient with osteoporosis
Prolonged steroid use
Osteoporosis
Age <20 and >70
History of cancer
Fever/chills/weight loss
Pain worse when supine or severe at night
Spinal fracture, tumor, or infection

Question 42

indications for MRI

Answer 42

Worsening or unremitting neurologic deficit or radiculopathy
Progressive major motor weakness
Cauda equina compression (sudden bowel/bladder disturbance)
Suspected systemic disorder (metastatic or infectious disease)
Failed six weeks of conservative care

not associated with clinical benefit

Question 43

Electrodiagnostics-Electromyography (EMG)

Answer 43

nerve conduction studies can be used in the evaluation of patients with radicular pain and lumbar spinal stenosis.

confirm the existence of radiculopathy (level of nerve involvement)

Question 44

Conservative therapy for acute low back pain includes:

Answer 44

Meds: Aspirin/NSAID and/or muscle relaxants

heat/cold

Activity: stay active or PT

Question 45

Treatment After Adequate Trial of Conservative Therapy

Answer 45

A. Surgery
B. It has only been five weeks, continue with current treatment
C. Acupuncture

Question 46

Spasm of the paraspinous muscles suggests

Answer 46

lumbosacral sprain/strain.