Case 10: Low Back Pain Flashcards
Most back pain resolves within…
two to four weeks
Congenital causes of lower back pain
Kyphosis (curved forward)
Scoliosis
Spondylolysis (Scotty dog fracture)
Traumatic causes of lower back pain
Lumbar strain
Compression fracture
Metabolic causes of lower back pain
Osteomalacia
Hyperparathyroidism
Paget’s disease
Osteoporosis
Infectious causes of lower back pain
Pyelonephritis Osteomyelitis Discitis Herpes zoster Epidural or spinal abscess
Inflammatory causes of lower back pain
Ankylosing spondylitis
Sacroilitis
Rheumatoid arthritis
Neoplastic causes of lower back pain
Multiple myeloma Metastatic disease Lymphoma Leukemia Osteosarcoma
Degenerative causes of lower back pain
Disc herniation
Osteoarthritis
Facet arthropathy
Spinal stenosis
Vascular causes of lower back pain
Aortic aneurysm
Diabetic neuropathy
Visceral causes of lower back pain
PID Prostatitis Endometriosis Kidney stones Pancreatitis Cholecystitis Ovarian cyst
3 major categories of back pain
- Mechanical (97%) - from bones, muscles, nerves
- Visceral (from internal organs)
- Non mechanical
3 most common causes of back pain
All mechanical
- Lumbar strain/sprain (70%)
- Age related degenerative joint changes
- Herniated disc
RFs for lower back pain (5)
- Prolonged sitting (truck driver, desk job)
- Deconditioning
- Sub optimal lifting and carrying habits
- Repetitive bending and lifting
- Spondylolysis, disc space narrowing, spina bifida
Red flags for serious illness or neuro impairment with back pain (5)
- fever
- unexplained weight loss
- pain at night
- neuro symptoms
- bowel or bladder incontinence
Disc herniation is worse with and better with?
Worse with sitting, leaning forward
Better with lying down or standing
Symptoms of disc herniation (4)
- increased pain with coughing/sneezing/valsalva
- radiation of pain down leg/foot
- paresthesias
- muscle weakness (foot drop)
Consider significant herniated nucleus pulposus
- major muscle weakness (=3 out of 5 strength)
- foot drop
Consider cauda equine syndrome if
- urinary incontinence or retention
- saddle anesthesia
- fecal incontinence
- bilateral LE weakness or numbness
- progressive neuro deficits
Prolonged use of corticosteroids increases probability of ______ ________ as source of LBP
Vertebral fracture (as does trauma, age >70, osteoporosis)
Recurrence of back pain is
High at 35 to 75%
Physical exam for LBP has 3 components
- standing
- sitting
- supine
Standing LBP physical exam
- Inspection for lordosis, kyphosis, scoliosis
- Palpation
- Range of motion: lumbar flexion, lumbar extension, lateral motion
- Gait: heel walk (L5) and toe walk (s1)
- Stoop test (go from standing to squatting) - in central spinal stenosis, squatting will reduce the pain
Seated LBP physical exam
- Check for CVA tenderness
- Modified straight leg raise test
- Neurological exam (to assess for nerve root impingement syndromes)
Modified straight leg raise test in seated LBP physical
Raise each leg while talking to pt
- if pain is functional, action is possible w/o difficulty
- if pain is structural, person will instinctively tripod (lean backward and support self with arms)
2/5 strength
Voluntary movement in plane of gravity
3/5 strength
Movement against gravity
4/5 strength
Movement against some resistance
L3
Patellar reflex
Sensation: lateral thigh
Motor: extend quads (squat down and rise)
L4
Patellar
Sensation: medial calf/ankle
Motor: dorsiflex foot (walk on heels)
L5
Sensation: lateral calf, dorsum of foot, big toe
Motor: dorsiflex big toe (walk on heels)
S1
Achilles reflex
Sensation: posterior calf, sole of foot, lateral ankle
Motor: Plantar flex ankle (walk on toes)
Supine LBP physical exam
- Abdominal exam (AAA, tenderness)
- Rectal exam only if there are alarm symptoms - look for bleeding or decreased done
- Passive straight leg test
- Crossed leg test
- FABER test
- Pelvic compression test
- Observe muscle atrophy
Straight leg test
Sensitive, but not specific (a negative test makes herniated disc unlikely)
Normal leg can be raised 80 degrees - + test if
- leg raised <80 degrees: sciatica (+ pain w dorsiflexion) or tight quads (no pain w dorsiflexion)
- pain that radiates down leg (disc herniation)
- pain in opposite leg (root compression due to central disc herniation)
Less sensitive and specific test than MRI
Crossed leg test
Raise asymptomatic leg
+ test if pain in contralateral leg: highlights degree of disc herniation - if positive, large central herniation present
FABER test
positive test indicates sacroiliitis
Pelvic compression test
Forcibly press hips together - positive test indicates sacroiliitis
Differential Dx for LBP
- Lumbar strain
- Disc herniation
- Degenerative joint disease
- Spinal stenosis
- Cauda equine syndrome
- Pyelonephritis
- Malignancy
- Ank spondy
- Spondylolisthesis
- Prostatitis
- Pancreatitis
- Spinal fracture
Pain worse with movement or sitting
Think mechanical cause
- lumbar strain
- disc herniation
- degenerative arthritis
Cauda equine syndrome
- due to large mass effect - acute disc herniation compresses the cauda equine - pain radiates down leg with numbness + bladder/bowel incontinence
- if present, DECOMPRESSION IN 72 HRs (surgical emergency)
Malignancy as cause of LBP
Pain localized to affected bones: dull, throbbing pain that progresses slowly that increases with cough
- seen in pts > 50
Ank spondy
Chronic, painful inflammatory arthritis primarily affecting spine and SI joints
- pts 15 to 40 yrs old
- Morning stiffness that improves with activity
Spondylolisthesis
Anterior displacement of vertebra or vertebral column
- any age
- aching back and posterior thigh discomfort that increases w activity or bending
Is early MRI associated with improved outcomes in patients with acute back pain or radiculopathy?
No!
75% of herniated discs improve with 6 weeks of conservative therapy
In absence of red flags or findings suggestive of systemic disease, diagnostic testing, is …
Not indicated until after 4-6 weeks of conservative management
Radiation exposure to ovaries in a single plain Xray of lumbar spine is equal to
Getting a daily chest Xray for more than a year
Conservative Tx for acute low back pain
- NSAIDs, acetaminophen, muscle relaxants
- local therapy with heat/cold
- NO bed rest- resume regular activities!
Referral to surgeon or advanced imaging (MRI/CT) should be considered if
Pain does not improve in 4-6 weeks or if neuro deficits appear/progress
- can also refer to pain clinic for epidural spinal injection
Opioids are
second line treatment for back pain
and oral steroids are never the answer
PT for LBP?
Some data shows that tailored PT is more effective for acute back pain compared to pts who just stay active
Acupuncture for LBP?
Limited evidence
