L-spine Flashcards
Red flags in lumbar pain include
<15 or >50 y/o Fever >100.4, or chills Significant trauma Unrelenting night pain Progressive sensory deficit Saddle anesthesia Urinary/fecal incontinence Major motor weakness Unexplained weight loss Hx or suspicion of cancer Hx of osteoporosis Hx of IVDU, steroid use, immunosuppression Failure to improve after 6 weeks of conservative Tx
Differential for red flags include .. and how do you test for them
Cancer: XR, CRP, ESR, CBC, alk phos, MRI or CT
Infection: XR, CRP, ESR, CBC, UA, alk phos
Fracture: XR, MRI or CT if XR inconclusive
Cauda Equina syndrome: MRI or CT STAT. STAT neuro consult
What is cauda equina syndrome
Dysfunction of 2+ nerve roots of the cauda equina
Can be caused by a herniated disc, epidural abscess, epidural tumor, lumbar spondylosis, sarcoidosis, or CMV, HSV, HZV, Lyme disease, mycoplasma, TB
Cauda equina presents with
bilateral sciatica bilateral LE weakness Saddle anesthesia Sphincter dysfunction (no rectal tone) Bowel or bladder dysfunction
What is acute low back pain
New onset low back pain <12 weeks duration
80% of population will experience at least one episode of disabling pain in their lifetime
Is mechanical low back pain bad?
No! The prognosis is good
If acute, 50% improve in one week, 80% return to work in 1 month
If chronic, 4% have pain lasting >6 months
What structures may be involved in acute low back pain
paravertebral spinal muscles
Facet joints
Ligamentous structures
RF for acute low back pain are
age obesity Physically strenuous work repeated twisting or bending job dissatisfaction Prolonged static posture (sedentary work) anxiety/depression
Does acute low back pain resolve quickly
Most cases are self limited and resolve in days- 4 weeks
Can self treat with ice or heat, and stretching hamstrings and hip flexors (psoas)
Why do people with acute loe back pain have trouble standing
Because when you sit, the psoas muscle shortens. Then upon standing, it spasms because it is not used to being stretched
What meds help acute low back pain
NSAIDs (Ketorolac aka Toradol)
Short course oral steroids
Muscle relaxants
What meds hould you NOT use to treat acute low back pain
Narcotics!
Try Tramadol or Acetaminophen before narcotics
With acute low back pain, to you need imaging?
No X-ray unless pain persists >4 weeks
Compression or irritation of a nerve root (radiculopathy) causes
pain sensory impairment weakness diminished deep tendon reflexes AKA: do good tests to find the distribution and locate the correct nerve root!
Explain common presentation for lumbar radiculopathy
1 month of low back pain
pain is worsening and radiates into his left leg
Pain is worse with lifting weights and playing with kids
No numbness, tingling, or weakness
no bowel or bladder dysfunction
no genital numbness or tingling
What test can be preformed to assess lumbar or sciatic nerve root irritation
Straight leg raise
Seated straight leg raise (to see if they are “malingering” aka bull shitting)
How do you preform the supine straight leg raise
Patient supine
Flex hip while maintaining knee extension
If radicular Sx produced, slowly lower leg until pain is gone, then dorsiflex the foot
Reproduction of radicular pain with dorsiflexion is (+)
-Radicular pain reproduced when testing the Oppo leg is specific for lumbar nerve root entrapment
How do you perform the seated straight leg raise
Patient seated
passively extend their knee to tension the sciatic nerve and lumbar roots
Patient not tolerating full knee extension is (+) (they lean back reflexively, or just complain of pain)
Reproduction of pain while testing Oppo knee extension is also (+)
What other testing is indicative of lumbar radiculopathy
Decreased sensation to light touch along lateral aspect of calf and dorsum of foot (can still tell sharp from dull)
First toe extension is 3/5
L5 is involved
All other dermatomes intact to sensation, myotomes are 5/5, reflexes are 2+
Surgical options in treating lumbar radiculopathy are
Laminectomy: Remove lamina allowing nerves more room
Disectomy: part of the lamina is removed to allow for a little extra room
How do you decide between ice and heat
Ice has analgesic properties and numbs
Heat is soothing and helps reduce muscle spasms
