Case 10 - 45 yo with low back pain Flashcards
Mechanical lower back pain (no inflammatory or neoplastic cause) risk factors and causes
Risk factors: obesity, deconditioning, prolonged sitting
Causes: lumbar strain, herniated disc, osteoporotic fracture, spinal stenosis, age related degenerative joint changes
Low back pain (LBP) epidemiology
Lifetime prevalence = 60-80%, most resolves in two to four weeks, 5th most common reason for all doctors visits
Radiologic findings associated with LBP
Spondylolysis, disc-space narrowing, spinal instability, spina bifida occulta
Prognosis of LBP
Most cases are acute in onset and resolution with 90% resolving in one month, older pts and those with stress take longer to recover, recurrence is 35-75%
Important history questions for LBP to rule out serious causes
Fever, n/v, wt loss, urinary/bowel incontinence, weakness, hx of cancer, trauma
Disc herniation history
Usually associated with exacerbation with sitting or bending, and relief with lying or standing, pain radiating down the leg, parsthesias, weakness like foot drop
LBP Physical Exam
Inspection: posture, contour, lordosis, scoliosis, kyphosis
Palpation
ROM: Lumbar flexion (worse with herniation, oA, muscle spasm), lumbar extension (worse with dJD or spinal stenosis), lateral motion (worse with herniation, OA for pain on same side, worse with muscle for pain on opposite side of bend)
Gait: Heel walk trouble = L5, toe walk trouble = S1
Stoop test: from standing to squatting, better with central spinal stenosis
Straight leg raise test
Muscle strength
Rectal exam in those with alarm sx - evaluate anal tone and presence of rectal mass/bleed
straight leg raise test
Pain should not start til >30 degrees. If unable to move to 80 degrees, pt has pathology. Positive if pain shooting down patients leg
FABER test
Tests for sacroiliac joint pain. Flexion, abduction, external rotation of hip
Differential diagnosis for 45 yo with LBP
More likely: Lumbar strain, disc herniation, spinal stenosis, DJD arthritis
Less likely: Cauda equina syndrome, malignancy, infection, vertebral fractures, significant herniated nucleus pulposis, GI dz, pyelo, ankylosing spondylitis, spondylolisthesis, prostatiitis
Presentation of cauda equina syndrome
Spinal compression of cauda equina, causes pain radiating down leg, leg numbness, urinary incontinence/retention, saddle anesthesia, anal sphincter decreased tone, progressive neuro deficits
This is an EMERGENCY, decompression w/i 72 hours
Studies for LBP
In the absence of alarm sx, diagnostic testing not indicated until completion of 4-6 weeks of conservative management
Indications for x-ray in LBP
Age 70, hx of trauma, osteoporosis, fever/chills/weight loss
Indications for MRI in LBP
neuro deficit, radiculopathy, progressive weakness, cauda equina compression, suspected systemic disorder, failure of 6 weeks of conservative care
Management of acute LBP
Conservative therapy: good posture, NSAIDs, muscle relaxants, avoid opioids and oral steroids, avoid strenuous activites but avoid bed rest, tailored physical therapy
