An Osteopathic approach to Low Back Pain & Herniated Nucleus Pulposus

Question 1

What are six DDx’s for localized LBP mechanical, without radiation below the knee?

Answer 1

¤Non-specific muscular and/or ligamentous injury
¤Somatic dysfunction
¤Degenerative disc disease
¤Degenerative joint disease
¤Spondylolithesis
¤Fracture/spondylolysis

Question 2

What are three DDx’s for LBP, mechanical with radiation below the knee?

Answer 2

¤Cauda Equina Syndrome
¤Radiculopathy
¤Spinal stenosis

Question 3

As far as positional clues go, what would you suspect for…

relief only with complete immobility?

Answer 3

¤Acute infection, compression or pathologic fracture

Question 4

As far as positional clues go, what would you suspect for…

¨Pain worsens with prolonged sitting or leaning forward”?

Answer 4

Herniated disc

Question 5

As far as positional clues go, what would you suspect for…

¨Pain worsens with prolonged standing and extension

Answer 5

¤“Shopping cart sign” – spinal stenosis

Question 6

As far as positional clues go, what would you suspect for…

¨No position is comfortable”?

Answer 6

¤Psychogenic pain

Question 7

What does radiating pain with extension indicate?

Answer 7

stenosis

Question 8

what does radiating pain at rest indicate?

Answer 8

disc herniation

Question 9

What does
¨Stiffness and pain upon waking” point to?

Answer 9

¤Inflammatory arthropathies

Question 10

What does Intense night time pain indicate?

Answer 10

Bone tumors

Question 11

What are some major redflags?

Answer 11

¨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

Question 12

How is the straight leg raise test performed?

Answer 12

“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.

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. 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.

Question 13

What are some areas that are likely causes of low back pain?

Answer 13

Latissimus dorsi

Quadratus lumborum

Iliopsoas

Sacro-iliac joint

Question 14

What are six things that can compromise the intervertebral foramina and disc?

Answer 14

¨Arthritis
¨Ligament hypertrophy
¨Disc degeneration
¨Muscle imbalance
¨Inherent tissue qualities
¨Somatic dysfunction

Question 15

Identify each herniation.

Answer 15

Question 16

What are the most herniated discs?

Answer 16

¨Most commonly herniated discs are L5-S1 and L4-5

Question 17

What are some HNP risk factors for low back pain?

Answer 17

¨Occupational lifting
¤Nurse, EMT, Construction worker, Firefighter, etc.
¨Bending or lifting precipitated the incident
¨Previous history of low back pain
¨Age
¨Tobacco use
¨Ethanol use

Question 18

Where does HNP pain radiate?

Answer 18

¤Down the back of the leg to the calf or foot

Question 19

Where does SD LBP pain radiate?

Answer 19

¤Down buttocks and anterior and posterior thigh
¤Rarely below the knee

Question 20

Describe the Tx plan for LBP

Answer 20

2. Rest (no confinement)
3. Continue exercise or physical therapy as tolerated
4. Continue anti-inflammatory treatment
5. Analgesics
6. Muscle relaxants
7. OMT

Question 21

What types of techniques are best for acute LBP?

Answer 21

indirect techniques are generally better tolerated – counterstrain, FPR, Still Technique, BLT, myofascial release, cranial

Question 22

What are good treatment options for subacute/chronic LBP?

Answer 22

indirect techniques are still fine but can incorporate direct as well – muscle energy, articulatory, HVLA

Question 23

What points to a need for surgery?

Answer 23

• Neurologic deficit
• Continued pain combined with 2 or all 3 of the following: paresthesia, reflex changes, and muscle atrophy
• Increase in intensity of symptoms despite conservative care
• When there is a clear picture of the etiology – DON’T CHASE PAIN