DSA Low Back Pain

Question 1

Acute low back pain

Answer 1

<12 weeks

high likelihood to resolve (no residual loss of fxn)

simple or no management required

Question 2

Chronic low back pain

Answer 2

> 12 weeks

high risk for loss of fxn/disability

tx resistant (need many different types of management)

Question 3

Risk factors for low back pain

Answer 3

lifting weight @ work
smoking
depression
obesity
inactivity

Question 4

What risk factors increase perception of pain?

Answer 4

smoking & depression

Question 5

Protective factors for low back pain

Answer 5

regular exercise (exercise is MOST important factor)

education + exercise (education is not effective alone)

Question 6

What are the common etiologies of low back pain?

Answer 6

Mechanical (97% of all causes)
Visceral Disease
Non-mechanical

Question 7

Describe visceral etiologies for low back pain

Answer 7

likely present as acute low back pain w/ other sxs

often is referred pain from abdominopelvic structures (GI organs, abdominal aorta, renal, GU organs, endometriosis)

Question 8

Describe non-visceral etiologies for low back pain

Answer 8

neoplasms (wt loss, deep bone pain @ night)
infection (fever, chills)
inflammatory (ankylosing spondylitis, psoriatic arthritis)

Question 9

What genotype is associated with low back pain due to inflammation?

Answer 9

HLA B27

Question 10

What are the major mechanical MSK etiologies of low back pain?

Answer 10

sprain/strain/overuse syndrome
piriformis syndrome
psoas syndrome
short leg syndrome

Question 11

Etiology of Sprain/Strain/Overuse syndrome

Answer 11

injury & stress on soft tissue structures (either injury to muscles or injury to ligaments)

Question 12

Pain pattern & DX of sprain/strain/overuse syndrome

Answer 12

aching pain over injured structure

DX by PE & palpation, by exclusion

Question 13

Etiology of Piriformis syndrome

Answer 13

hypertonicity of piriformic muscle, nerve entrapment of sciatic nerve (as exits btwn priformis & superior gemelllus muscles)

Question 14

Pain pattern & DX of piriformis syndrome

Answer 14

worse w/ sitting & @ risk if have trauma or overuse

DX w/ PE & + FAIR test (reproduces pain w/ Lat recumb, flex, IR & AB)

Question 15

Etiology of psoas syndrome

Answer 15

chronic hypertonicity of psoas muscle (from T12-L4 to greater trochanter)

Question 16

Pain pattern & DX of psoas syndrome

Answer 16

pts will hunch/flex lumbar spine & have pain originating @ thoracolumbar junction or as hip pain

pain will worsen w/ lumbar extension & standing straight up

DX by palpation of muscle, + Thomas test, Pelvic side shift will resolve w/ manipulation

Question 17

Etiology of pelvic side shift

Answer 17

innominate is shifted to R or L of midline

Question 18

DX of pelvic side shift

Answer 18

laterally translate innominate to test for preference during postural exam

+R pelvic side shift (pelvis translates to R but resists motion to L)

Question 19

Etiology of short leg syndrome

Answer 19

anatomic leg length discrepancy creates sacral base unleveling leading to MSK stress imbalance

Question 20

Pain pattern & DX of short leg syndrome

Answer 20

presents similar to overuse syndrome (pain in affected structures above low back)

common w/ scoliosis & will worsen w/ activity or walking

DX by PE (pelvic side shirt will NOT resolve & translates away from short leg), postural Xray

Question 21

How do you tx short leg syndrome?

Answer 21

tx ONLY is leg length discrepancy if >5mm or >1/5 inch

add 1/8 (flexible) or 1/16 (fragile) inch every 2 weeks

**if acute change in leg length, replace full discrepancy immediately

Question 22

Etiology, pain pattern & DX of degenerative disc dz

Answer 22

degeneration leads to stress & inflammation of nociceptors (in annulus fibrosis)

non-specific pain pattern, risk w/ age & inactivity, will worsen w/ bending forward or sneeze/cough

DX w/ Xray

Question 23

Etiology, pain pattern & DX of spondylolysis

Answer 23

defect/stress fracture of pars interarticularis

usually asymptomatic w/ any pain usually over L5, risk if young athlete & worsens w/ hyperextension

DX w/ X ray demonstrating Scotty dog sign

Question 24

Etiology, pain pattern & DX of spondylolisthesis

Answer 24

anterior displacement of vertebrae secondary to bilateral pars defects

non specific pain pattern (usually @ L4/L5), risk w/ age or if have bilateral spondylolysis, worsens w/ extension & activity

DX w/ palpable “step off” on PE, can see on X ray

Question 25

Etiology, pain pattern & DX of compression fracture

Answer 25

> 20% vertebral height, acute atraumatic fracture or chronic loss

most are asymptomatic (40% are women over 80yo) or have acute lower mid thoracic pain, risk w/ age & osteoporosis, worsens w/ sitting or extension & movement

DX w/ X ray

Question 26

Etiology, pain pattern & DX of spinal stenosis

Answer 26

narrowing of neural foramen or central canal

unilateral numbness & tingling (over L4, L5, S1 nerve roots), risk w/ age & OA & will worsen w/ standing or walking but better w/ sitting/lying down

DX w/ MRI

Question 27

How does spinal stenosis present?

Answer 27

classical shopping cart sign

numbness, tingling w/ extension, standing & walking

better w/ flexion, leaning forward & sitting

Question 28

Etiology, pain pattern & DX of herniated disk

Answer 28

compression of nerve root due to herniation of nucleus pulposus thru annulus fibrosus

pain affects discs btwn L4-L5 (L5 nerve root) & L5-S1 (S1 nerve root)

risk w/ occupation (if lots of twisting) & worsens w/ flexion

DX w/ MRI

Question 29

Etiology, pain pattern & DX of cauda equina syndrome

Answer 29

massive disc herniation compressing the cauda equina

numbness & tingling in perinuem (saddle anesthesia w/ lower anal sphincter tone), will have fecal & urinary incontinence

risk if trauma & worsens w/ TIME

DX w/ MRI

Question 30

What is essential for tx of cauda equina syndrome?

Answer 30

is an EMERGENT situation (cannot delay tx b/c can lead to permanent incontinence & disability)

tx w/ emergent spinal decompression

Question 31

What are the red flags in a workup for low back pain?

Answer 31

progressive LE weakness (progressive radiculopathy)

saddle anesthesia/loss of bladder control (cauda equina syndrome)

deep bone pain/unexplained wt loss (neoplasm)

fever/chills (osteomyelitis)

Question 32

Describe imaging guidelines for pt w/ low back pain

Answer 32

AVOID IMAGING (do NOT order imaging w/ in 1st 6 weeks unless there is progressive neuro deficient)

must start w/ conservative tx!!

Question 33

What are types of conservative management for low back pain?

Answer 33

reassurance (good prognosis, tell pt that will most likely get better)

continue activity (avoid bed rest & EXERCISE)

topical ointments, muscle relaxer, anti-depressants

PT/manipulation/OMM

Question 34

What are the common SD assoc w/ back pain?

Answer 34

muscle imbalance 
lumbar spine type 2 SD
pubic symphysis dysfunction
short leg
sacral extension dysfunction
innominate shear

Question 35

When would you use invasive therapy for low back pain?

Answer 35

after failure of conservative therapies

Question 36

What are some invasive therapy techniques for back pain?

Answer 36

epidural injection (steroid around nerves)
facet injection (steroid @ joint)
radiofrequency ablation (burn out nerves causing pain)
spinal surgery (decompression or fusion)

Question 37

What is the last resort therapy for back pain?

Answer 37

fusion spinal surgery b/c usually causes chronic pain

Question 38

What is important for proper work up & tx of low back pain?

Answer 38

most low back pain is mechanical & will resolve in 12 weeks

many modalities to tx low back pain & should use multiple if tx resistant (OMM, exercise, PT all have strong evidence in setting of chronic low back pain)