Back Pain Flashcards
1
Q
Low Back Pain (LBP)
Definition
A
- Symptom and not a diagnosis
- Need to determine the etiology causing the back pain
- Acute is < 12 weeks
- Chronic is > 12 weeks
2
Q
LBP
Epidemiology
A
- Lifetime prevalence of LBP = 60-70%
- Only 30% seek care
- 2.5% total health care spending in U.S.
- Chronic back pain is an economic burden for U.S
3
Q
LBP
Timeline
A
-
Most cases are self-limited
- 60% better in 1 week
- 90% better in 6 weeks
- 95% better in 12 weeks
-
Relapses/recurrences common
- 25-40% within 6 months
- Screen for “red flags” to detect serious causes of LBP
4
Q
Spinal Anatomy
Review
A
- C1-C7 nerve roots exit above the vertebrae
- C8 root and below exit below corresponding vertebra
- Flexion increases the size of the spinal canal; extension decreases it
- Spinal cord ends at L1 vertebral level
- Tapers into conus medullaris then into cauda equina
5
Q
LBP
Differential Diagnosis
A
-
Mechanical LBP (97% of LBP)
- Lumbar strain (70%)
- Degenerative disc disease / facet (osteoarthritis)
- Herniated disc
- Spinal stenosis
- Spondylolisthesis
- Osteoporotic compression fracture
-
Non-mechanical Spinal Conditions (1%)
- Tumor
- Infection
- Inflammatory Arthritis
-
Non-spinal (visceral disease) (2%)
- Pelvic organs (pelvic inflammatory disease / prostatitis)
- Renal (nephrolithiasis / pyelonephritis)
- Aortic aneurysm
- GI (pancreatitis / peptic ulcer disease)
6
Q
Lumbar Strain
A
- Due to strain of muscle fibers and/or ligaments
- Bleeding and spasm ⇒ tenderness and stiffness in lumbar region
- Pt usually recalls precipitating incident (lifting/twisting) with immediate onset of pain
- Pain better when lying supine
- No neurologic signs/symptoms
- Pain is local and though may radiate to posterior thighs/buttocks
- DOES NOT radiate below knee d/t no nerve root involvement
7
Q
Degenerative Disc Disease
A
“Osteoarthritis of Spine”
- Causes chronic back pain
- Narrowing of disc spaces and osteophyte formation
- May cause radicular symptoms / nerve root compression
8
Q
Herniated Lumbar Disc
A
Tear of annulus fibrosis ⇒ extrusion of nucleus pulposus
- Highest prevalence 45-64 year age group
- 95% occur at L4-L5 or L5-S1
- Classically precipitated by sudden increased pressure on disc (coughing/lifting)
- Usually near midline ⇒ compress the nerve root of the vertebra below
- Moderate to severe pain with radiation to ankle/foot
- Paresthesias or motor weakness due to pressure on nerve root
- No bowel/bladder symptoms with unilateral disc herniation
- Symptoms usually unilateral
-
Forward flexion makes pain worse
- Sitting (including driving) and lifting
9
Q
Spinal Stenosis
A
Narrowing of the spinal canal
- Usually degenerative but may be due to trauma/congenital abnormalities
- Gradual worsening
- Leg symptoms usually bilateral
- Neurogenic claudication
- Worse with activity (standing/walking) and spine extension
- Relieved with bending forward or sitting
10
Q
Claudication Comparison
A
11
Q
Sciatica
A
- Sciatic nerve is derived from L4-S3 nerve roots
- Sciatica ⇒ compression or irritation of sciatic nerve by a low back problem
- Form of radiculopathy
- Symptom not a specific diagnosis
- Etiologies include herniated disc, spinal stenosis, or DDD
12
Q
Cauda Equina
Syndrome
A
Rare condition caused by tumor or massive midline disc herniation compressing multiple sacral roots.
-
Features:
- Back pain
- Urinary retention (loss of detrusor function)
- Decreased anal sphincter tone
- Saddle distribution of sensory loss
- Bilateral sciatica
- Leg weakness
- Medical emergency ⇒ needs imaging ASAP and decompression
13
Q
LBP
History
A
-
Onset
- Acute vs. chronic
- Precipitating event / Mechanism of injury
- Trauma?
- Sudden vs gradual onset of pain
-
Character
- Sharp vs dull
-
Location and Radiation
- Lumbar strain ⇒ paraspinous muscle pain +/- radiation to buttocks
- Bone pain (metastasis/compression fx) ⇒ usu. localized to spine
- Radiation below knee ⇒ herniated disk
- Spinal stenosis ⇒ pain radiating into both legs
- Cauda equina syndrome ⇒ bilateral symptoms
-
Intensity
- Severity of pain doesn’t correlate well with etiology
- Patient factors
- Gauge it over time OR how it affects daily activities
-
Duration
- > 12 weeks ⇒ chronic
- Continuous vs waxes/wanes
- Rheumatic causes ⇒ initial stiffness/pain that ↓ over a few hrs
- Disc stiffness ⇒ ↓ after 20-30 mins
- Spinal stenosis ⇒ ↑ with activity
-
Aggravating Factors
- Valsalva, coughing or bending forward ⇒ ↑ pain with disc herniation
- Worse with walking downhill or downstairs ⇒ spinal stenosis
-
Relieving Factors
- Prescription or OTC meds tried
- Positions that decrease pain
-
Psychosocial Factors
- Assess how pain is affecting patient’s lifestyle
- Beliefs about prognosis/any litigation or disability issues
-
Associated Symptoms
- Red flag symptoms
- Urinary, gynecologic or abdominal symptoms ⇒ ? visceral pathology
14
Q
LBP
Red Flags
A
15
Q
LBP
Physical Exam
A
-
Inspect:
- Posture
- Curvatures
- Spinous processes
- Paraspinous muscles
-
Palpate:
- Spinous processes/paraspinous muscles
-
Range of motion of lumbar spine
- Flexion
- Extension
- Lateral bending
- Rotation
- Any movement worsen pain?
- Neurologic exam
- Abdominal exam, pelvic or prostate exam as indicated
- Special tests ⇒ SLR
16
Q
LBP
Neurologic Exam
A
-
Motor strength:
- Look for asymmetry
- Grade on scale of 0-5
- Full ROM against gravity w/ max resistance (5)
- Full ROM against gravity w/ some resistance (4)
- Full ROM against gravity w/ no resistance (3)
- Full ROM with gravity eliminated (2)
- Partial ROM with gravity eliminated (1)
- No movement detected (0)
-
Deep tendon reflexes
- Patellar tendon reflex (knee jerk) – mainly L4
- Achilles reflex (ankle jerk) – mainly S1
- Sensation
