Approach to Low Back Pain Flashcards
3 categories of back pain
Nonspecific
Radiculopathy or spinal stenosis
Systemic dz
Red flag sx of note
Over 50 System sx Cancer Night pain or worse with rest Urinary probs Infection (skin and urinary) Immunosuppression Drug use Durgs or osteoposis Failrue to response Trauam
Inspection
Palpation and percussion
INspect for curvature
Palpate each process for tenderness or step-offs
Stepo-offs may man spondylolisthesis
Pain is fracture,infection or arthritis
Palpate SI at L5 level…tenderenss is spondyloarthropathy
Palpate paravertebral muscles
Percuss for tenderness with unlar surface of fist of ver vertebra
ROM and special maneuvers
Flexion, extn, rotation, and lateral bending
Striaght lef raise - assesses for nerve root compression (sensitive)…lift affect extended leg…if pain in leg, extending blow knee then positive
Corssed straight leg rasie - specific for nerve root compression….supine and life unaffected leg…if pain in affected leg, then positive
Modified schober - mark of L5 and 10cm above that…when patients bends, distance hsould increase by 5 cm
L4 muscle, sensory, motor, screening, reflexes
Anterior tbilias
Medial calf and ankle
Extension of quads
S
Squatting and rising
Patellar
L5 muscle, sensory, motor, screening, reflexes
Extensor hallicus longus
Lateral ankle and dorsum of foot
Dorsiflexion of foot and great toe
Walking on heels
Not reliable
S1 muscle, sensory, motor, screening, relfx
Gastrocnemi,s sleus, peroneals
Planater-lateral foot
Plantar flexion of foot and great toe
Walk on toes
Ankele
Lumbar strain/spain
Lumbargo
Paraspinal muscle injury
Lumbar sprain is ligamentous injury
Can radiate to butt or post thight
Worse with activity and bening
May be after excessive use
Tenderness over paraspinals and restricted ROM, esp flexion
NSAIDS and strethcing for 4-6 weeks
Degeenrative dz
Spondylosis - intervetrt discs
OA- facet joints
As IV disk lost, it bulges and infolds the ligamentum flavum
Stres on facet joints leading to OA
Chronic dull ache
Maybe morning early stiffness lasting less than 15
Difficult to distinguish from lumbar strain
Scoliosis
Lateral curvature accompanied by rotation
Most are idiopathic
Pain in areas of defotmity
Adams forward bend test - bend at wait while keeping knees stragith…if positive, then rotational deformity with more prominency of ribs/scap on the right side
Can X-ray
NSAIDs and exercise
Kyphosis
Roundback defomrity opf thoracic spine
Convexity
Usually with aging
Thoracic back pain
Pain control and tx underlying osteoporosis
Compression fracture
Often no acute inciting event
Tenderness to palpation over the spinous process
Loss of vertebrla hegith on X ray
Pain managmenet, and osteroporotic management
Lumbar herniated disc
Herniation ovetime as weak posterolateral portion of annulus fibrosis develops fissures
Material creates chem irritation and compressive ffect on nerve root
Pain, numbness or wekaness in one of lower exteemitieis
Radiculus leg pain below knee follows onset of back pain
SCoughing and sneezing make it worse
MRI if sx byond 4-6 weeks
NSAIDs primary
epidural steroids in refractory
Spinal stenosis
Neurogenic claudication
Intervertebral disc degeneration leads to load shifted to facet joints
Fact osteoarthritis and hypertrophy leads to osteophytes
Narrowing of canal, facet joints, or neural fromaina
Radiation in buttock and thigh/lower leg
Wrose with lumbar extesnions and improved with lumbar flexion
True weakness uncommon
Propioception may be impaired with wide gait and positive romberg
Tx with NSAIDs and PT intiially…surgery if not
Degenrative spondylolisthesis
Forward slip of vertebra due to degen changes in facet and IV diskl
Over 40 and obese
Pain made worse with bending, twist, lifting
X-ray will show narrowing of joint space with IV disc slippage
Manage with NSAIDs, weight loss and exercise…may need surgery
Cauda equina
L2-S4 compression of multiple roots
Numbness in both legs, saddle paresthesia, incontinence, and weakness
Motor and sensory dysfunction
Decreased sphincter tone
Urinary retention
Emergent MRI and neurosurg eval…this is an emergecn y
Spondyloarthrophy/AS
Persistent lower back pain in teens to 20s
Stooped posture and loss of mobility
SI tenderness
Schober test shows reduced flexibility
Sacroilitis
Vertebral osteomyelitis
Heamtogenous, direct trauama/spinal surgery, or from soft tissue
Risk - IV, endocarditis, diabetes, immunocomp, spinal surg, older age
Segmental arteries supply blood to the vertebrae…arteries bifurcate and supply to inferior of one end plate and superior of other…infection typically involves 2 adjacenrt vertebral bodies and their IV disk
Back pain insidious and worsns over weeks
Tenderness of spinous processes
WBC and ESR elevated
Blood cultures positive most of the time
MRI is best test…ABs for at least 6 weeks
Epidural abscess
Collection of pus between dura and vertebral column
Infection can invade via hematogenous psread or direct extension
Similar risk of osteomyleitis
Most common S auresu
Tirad of fever, back pain, and neuro deficits
WBC and ESR/CRP elevated
MRI is preferred
Srugical decompression, asbcess drainage, and L-T AB therpay
Spianl metastases
Over 50m hx of cancer, or weight loss
Majority from carcinoma of breast, lung, portate, co,on, thyroid, or kidney
Progressive unrelenting pain worse at night is typical
Maybe radiculopathy
Tenderness along spinous processes
X-ray - loss of vertebral hieght or bny destruction with lytic or blastic lesions
MRI may be best
Bone scan can help but neg in multiple pyemloma
Dscitis - toddlers
Under the age of 5, infection because of heavily vascularized disks and bacteremia
Graudal refusal to walk or a limp
Fever absent
Increase WBC and CRP/ESR
Important ot obstain blood cultures, but rarely positive
X-rays normal initially then show narrowing/plate changes
MRI is best
AB course
Malignant tumors - toddlers
Unrelenting, progressive apin worse at night
Osteosarcoma and Ewings are most common primary…could also be from leukemia or metastitc dz
Leukemia may be associated with compression fractuers
Bone scan
Vertebral osteomyelitis - schoo age
Spread form skin or other site
Insidious onset of constant back pain and resist walking
May appear ill and site may be inflamed
Increased WBW and CRP/ESR
Blood cultures essentials
X-rays negatvie for 10-14 days then periosteal thickening, elevation and focal osteopenia
MRI is best
Tx with extendied AB course
Benign bone tumors - school aged
Osteoid osteoma and bone cysts
Osteoid - night pain relieved by NSAIDs and resolve on own
Cysts - chronic dull pain and can cause pathologic fracture…can see on X-ray but MRI pathologic
MSK pain in adolescents
Chronic and intermittent related to overuse and poor mechanics
Tenderness over paraspinals or tight hamstrings
NSAIDs and PT…bed rest avoided…no imaging needed
Spondylolysis - adolescents
Repitivie hyperextension of the lumbar spine due to sports
X-ray defect in pars interarticularis
Pain worse with extension and rleieved by flexion
Paraspinal tenderness and tight hamstrings with pain on extension
Activity mod, complete rest, full time bracing and retunr in 2-4 months
Spondylolisthesis - adolescents
Uncommon
Bilateral fracture of pars interarticularis leads to anterior slippage of vertebra…more at L5-S1
Sx similar to spondylolysis but may have neuro sx
Kypohosis - adolsecents
Most due to poor posture
May result from prolonged sitting
X-ray normal
PT
Scheurmann disorder is angled deformity of vertebral bodies…typically familial…typical toracic or thoracolumbar pain with activiy…X-ray shows anterior wedging of multiple vertebral bodfies…may need NSAIDs, PT, surg
Idiopathic soliosis - adolescents
Most common
Abnormal curvature iwth oration
More in females
If adam forward bend test is abnormal, then scoliometer used to measure rotation
X-ray shows curvature
Angle reater than 10 degrees is diagnositic
Tx depends on sverity
