DSA Low Back Pain Flashcards
Acute low back pain
<12 weeks
high likelihood to resolve (no residual loss of fxn)
simple or no management required
Chronic low back pain
> 12 weeks
high risk for loss of fxn/disability
tx resistant (need many different types of management)
Risk factors for low back pain
lifting weight @ work smoking depression obesity inactivity
What risk factors increase perception of pain?
smoking & depression
Protective factors for low back pain
regular exercise (exercise is MOST important factor)
education + exercise (education is not effective alone)
What are the common etiologies of low back pain?
Mechanical (97% of all causes)
Visceral Disease
Non-mechanical
Describe visceral etiologies for low back pain
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)
Describe non-visceral etiologies for low back pain
neoplasms (wt loss, deep bone pain @ night)
infection (fever, chills)
inflammatory (ankylosing spondylitis, psoriatic arthritis)
What genotype is associated with low back pain due to inflammation?
HLA B27
What are the major mechanical MSK etiologies of low back pain?
sprain/strain/overuse syndrome
piriformis syndrome
psoas syndrome
short leg syndrome
Etiology of Sprain/Strain/Overuse syndrome
injury & stress on soft tissue structures (either injury to muscles or injury to ligaments)
Pain pattern & DX of sprain/strain/overuse syndrome
aching pain over injured structure
DX by PE & palpation, by exclusion
Etiology of Piriformis syndrome
hypertonicity of piriformic muscle, nerve entrapment of sciatic nerve (as exits btwn priformis & superior gemelllus muscles)
Pain pattern & DX of piriformis syndrome
worse w/ sitting & @ risk if have trauma or overuse
DX w/ PE & + FAIR test (reproduces pain w/ Lat recumb, flex, IR & AB)
Etiology of psoas syndrome
chronic hypertonicity of psoas muscle (from T12-L4 to greater trochanter)
Pain pattern & DX of psoas syndrome
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
Etiology of pelvic side shift
innominate is shifted to R or L of midline
DX of pelvic side shift
laterally translate innominate to test for preference during postural exam
+R pelvic side shift (pelvis translates to R but resists motion to L)
Etiology of short leg syndrome
anatomic leg length discrepancy creates sacral base unleveling leading to MSK stress imbalance
Pain pattern & DX of short leg syndrome
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
How do you tx short leg syndrome?
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
Etiology, pain pattern & DX of degenerative disc dz
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
Etiology, pain pattern & DX of spondylolysis
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
Etiology, pain pattern & DX of spondylolisthesis
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
Etiology, pain pattern & DX of compression fracture
> 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
Etiology, pain pattern & DX of spinal stenosis
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
How does spinal stenosis present?
classical shopping cart sign
numbness, tingling w/ extension, standing & walking
better w/ flexion, leaning forward & sitting
Etiology, pain pattern & DX of herniated disk
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
Etiology, pain pattern & DX of cauda equina syndrome
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
What is essential for tx of cauda equina syndrome?
is an EMERGENT situation (cannot delay tx b/c can lead to permanent incontinence & disability)
tx w/ emergent spinal decompression
What are the red flags in a workup for low back pain?
progressive LE weakness (progressive radiculopathy)
saddle anesthesia/loss of bladder control (cauda equina syndrome)
deep bone pain/unexplained wt loss (neoplasm)
fever/chills (osteomyelitis)
Describe imaging guidelines for pt w/ low back pain
AVOID IMAGING (do NOT order imaging w/ in 1st 6 weeks unless there is progressive neuro deficient)
must start w/ conservative tx!!
What are types of conservative management for low back pain?
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
What are the common SD assoc w/ back pain?
muscle imbalance lumbar spine type 2 SD pubic symphysis dysfunction short leg sacral extension dysfunction innominate shear
When would you use invasive therapy for low back pain?
after failure of conservative therapies
What are some invasive therapy techniques for back pain?
epidural injection (steroid around nerves) facet injection (steroid @ joint) radiofrequency ablation (burn out nerves causing pain) spinal surgery (decompression or fusion)
What is the last resort therapy for back pain?
fusion spinal surgery b/c usually causes chronic pain
What is important for proper work up & tx of low back pain?
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)
