10- low back pain Flashcards
most low back pain clears up in how long
2-4 weeks
What are the three most common causes of back pain?
lumbar strain- 70%
disc herniation
degenerative joint disease
Acute sciatica
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.
Risk Factors for Low Back Pain
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
Red Flags For Serious Illness or Neurologic Impairment with Back Pain
Fever Unexplained weight loss Pain at night Bowel or bladder incontinence Neurologic symptoms Saddle anesthesia
Pain worse with movement and sitting is suggestive of
a mechanical cause of back pain, such as a lumbar strain, disc herniation,or degenerative arthritis.
Pain radiating down the leg and numbness indicate
nerve involvement, such as in disc herniation.
Pain that improves with the supine position suggests
spinal stenosis and disc herniation.
Cauda equina syndrome
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
Ankylosing spondylitis
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.
back pain presentation in context of malignancy
localized to the affected bones, it is a dull, throbbing pain that progresses slowly, and it increases with recumbency or cough.
> 50 yo
Spondylolisthesis
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.
which GI disorders can cause back pain
pancreatitis
cholecystitis
ulcers
Restriction and pain during flexion are suggestive of
herniation, osteoarthritis, or muscle spasm.
Pain with extension is suggestive of
degenerative disease or spinal stenosis.
pain with lateral motion indicates
pain on the same side as bending= bone pathology, such as osteoarthritis or neural compression.
Pain on the opposite side of bending: muscle strain.
Difficulty with heel walk is associated with
L5 disc herniation
Difficulty with toe walk is associated with
S1 disc herniation
squatting will reduce the pain in what disease
central spinal stenosis
muscle strength rating scale
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
L3 Reflex Pin-Prick Sensation Motor Examination Functional Test
Reflex: Patellar tendon reflex
Pin-Prick Sensation: Lateral thigh and medial femoral condyle
Motor Examination: Extend quadriceps
Functional Test: Squat down and rise
L4 Reflex Pin-Prick Sensation Motor Examination Functional Test
Reflex: Patellar tendon reflex
Pin-Prick Sensation: Medial leg and medial ankle
Motor Examination: Dorsiflex ankle
Functional Test: walk on heels
L5 Reflex Pin-Prick Sensation Motor Examination Functional Test
Reflex: Medial hamstring
Pin-Prick Sensation: Lateral leg and dorsum of foot
Motor Examination: Dorsiflex great toe
Functional Test: Walk on heels
S1 Reflex Pin-Prick Sensation Motor Examination Functional Test
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
what is indicative of “tripod sign” in straight leg test? ( leaning backward and supporting himself with his outstretched arms on the exam table.)
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.
muscle tests to do in supine
abdominal: auscultate (aneuryms) and palpate for tenderness
Passive Straight Leg Raise
cross leg raise test
FABER
muscle atrophy
Passive Straight Leg Raise normal degree
80 degree
To differentiate between tight hamstrings and a sciatic nerve problem in straight leg test
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.
what does it mean when theres pain less than 30 degrees in straight leg test?
malingering! no disc herniation
Crossed Leg Raise
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.
FABER Test:
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.
hints of history it’s disc herniation
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
Urinary retention is part of which back disorder
cauda equina syn
how is disc herniation resolved?
typically self-limited and usually resolves in two to four weeks,
what are other red flags for caua equina syn
urinary retention
Saddle anesthesia
Anal sphincter tone decreased or fecal incontinence
Bilateral lower extremity weakness or numbness
Progressive neurologic deficits
Significant Herniated Nucleus Pulposus hints
Major muscle weakness (strength 3 of 5 or less)
Foot drop
red flags for vertebral fracture
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
red flags for infection
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)
red flags for cancer
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
when should CBC and ESR be ordered?
if tumor or infection is suspected.
indications for x ray
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
indications for MRI
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
Electrodiagnostics-Electromyography (EMG)
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)
Conservative therapy for acute low back pain includes:
Meds: Aspirin/NSAID and/or muscle relaxants
heat/cold
Activity: stay active or PT
Treatment After Adequate Trial of Conservative Therapy
A. Surgery
B. It has only been five weeks, continue with current treatment
C. Acupuncture
Spasm of the paraspinous muscles suggests
lumbosacral sprain/strain.
