Back Pain

Question 1

How common is low back pain as a reason to see a primary care physician?

Answer 1

3rd most common reason for a primary care visit, number 1 cause of disability under the age of 45

Question 2

What are some common causes of low back pain?

Answer 2

Disc pathologies (degenerative disc disease, internal disc disruption, disc herneations), facet joint mediated pain, muscle injury, sacroiliac joint mediated pain, or referred pain from the hip

Question 3

What are the key steps to making a diagnosis in patients with low back pain and coming up with a treatment plan?

Answer 3

Key steps to making a diagnosis includes a thorough history and physical exam. Imaging can help if pain is not responding to treatment, if considering interventional procedures, or if there are neurologic defects, suspician for fracture/infection, or other red flags

Question 4

What are some common treatment options for low back pain?

Answer 4

Common treatment options include modalities and medications to reduce pain, inflammation, early mobilization/activity modification, physical therapy. PT can be helpful when identifying subgroups of pain generators, directional preference in an effort to abolish symptoms and restore pain-free movement. Injections may also be involved.

Question 5

Where in the spine does the greates motion occur?

Answer 5

L4-5 and L5-S1

Question 6

How does the intervertebral canal size change with back motions?

Answer 6

Canal size decreases with extension, increases with flexion

Question 7

How does facet load change with different back positions?

Answer 7

It increases with extension and decreases with flexion

Question 8

Which of the following positions puts the most amount of pressure on the disc?

a) sitting in poor posture
b) laying on the side
c) bending forward
d) standing
e) bending backwards

Answer 8

a) sitting in poor posture

Question 9

What is discogenic low backpain?

Answer 9

Pain caused by anintervertebral disc, irritation of nerve receptors innervating annulus fibrosus and periosteum

Question 10

What is the positioning that changes pain level in discogenic low back pain?

Answer 10

Axial pain, worse with flexion and valsalva maneuvers

Question 11

What are disc hearnations?

Answer 11

Pain caused when disc material extends outside of intervertebral disc space, most common in people > 55 yo and in the L4-5 or L5-S1 vertebrae

Question 12

What is lumbar radiculopathy?

Answer 12

Nerve root compression or inflammation that causes lancinating pain radiating to leg in a dermatomal distribution (+/- back pain)

Question 13

What is a zygapophysial joint?

Answer 13

It is pain that is typically worse with extension and occurs in z-joint/facet joints in the L4-5 and L5-S1 vertebrae

Question 14

Which position would typically provoke symptoms in a patient with lumbar stenosis?

a) prolonged sitting
b) walking uphill
c) bending forward
d) prolonged walking

Answer 14

d) prolonged walking

Question 15

What is spinal stenosis?

Answer 15

Narrowing of the spinal canal that causes neurogenic claudication pain (pain with walking, prolonged standing, and downhill walking)

Question 16

What is the shopping cart sign?

Answer 16

A phenomenon associated with spinal stenosis where pain is relieved with sitting, bending foward, or walking uphill

Question 17

In back pain, what other joint area is important to evaluate?

Answer 17

Hip pain - referred hip pain can present as back pain

Question 18

When should you consider imaging in back pain?

Answer 18

• if pain isn’t responding to treatment
• suspected fracture
• neurologic deficits
• suspected vertebral infection
• suspected cancer
• considering intervention/surgery

Question 19

What sources of back pain are visible with x-ray?

Answer 19

Fracture, alignment (spondylolisthesis), disc height loss

Question 20

What sources of back pain are visible on MRI?

Answer 20

Internal disruption of disc, z-joint arthropathy, stress reaction, fracture, infection, tumor, central/foraminal narrowing, nerve impingement

Question 21

What are the treatments for acute back pain?

Answer 21

Decrease pain/inflammation (NSAIDs), early mobilization, direct movement pattern to centralize pain

Question 22

What is mechanical diagnosis and therapy (MDT)?

Answer 22

A program to restore pain-free movement and identify directional preference

Question 23

What are indications for surgical referral?

Answer 23

Cauda equina symptoms, progressive neurologic deficit, suspeted spinal cord compression, clearly failed comprehensive trial of non-surgical interventions