L-spine

Question 1

Red flags in lumbar pain include

Answer 1

<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

Question 2

Differential for red flags include .. and how do you test for them

Answer 2

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

Question 3

What is cauda equina syndrome

Answer 3

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

Question 4

Cauda equina presents with

Answer 4

bilateral sciatica 
bilateral LE weakness 
Saddle anesthesia 
Sphincter dysfunction (no rectal tone) 
Bowel or bladder dysfunction

Question 5

What is acute low back pain

Answer 5

New onset low back pain <12 weeks duration

80% of population will experience at least one episode of disabling pain in their lifetime

Question 6

Is mechanical low back pain bad?

Answer 6

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

Question 7

What structures may be involved in acute low back pain

Answer 7

paravertebral spinal muscles
Facet joints
Ligamentous structures

Question 8

RF for acute low back pain are

Answer 8

age 
obesity 
Physically strenuous work 
repeated twisting or bending 
job dissatisfaction 
Prolonged static posture (sedentary work) 
anxiety/depression

Question 9

Does acute low back pain resolve quickly

Answer 9

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)

Question 10

Why do people with acute loe back pain have trouble standing

Answer 10

Because when you sit, the psoas muscle shortens. Then upon standing, it spasms because it is not used to being stretched

Question 11

What meds help acute low back pain

Answer 11

NSAIDs (Ketorolac aka Toradol)
Short course oral steroids
Muscle relaxants

Question 12

What meds hould you NOT use to treat acute low back pain

Answer 12

Narcotics!

Try Tramadol or Acetaminophen before narcotics

Question 13

With acute low back pain, to you need imaging?

Answer 13

No X-ray unless pain persists >4 weeks

Question 14

Compression or irritation of a nerve root (radiculopathy) causes

Answer 14

pain 
sensory impairment 
weakness 
diminished deep tendon reflexes 
AKA: do good tests to find the distribution and locate the correct nerve root!

Question 15

Explain common presentation for lumbar radiculopathy

Answer 15

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

Question 16

What test can be preformed to assess lumbar or sciatic nerve root irritation

Answer 16

Straight leg raise

Seated straight leg raise (to see if they are “malingering” aka bull shitting)

Question 17

How do you preform the supine straight leg raise

Answer 17

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

Question 18

How do you perform the seated straight leg raise

Answer 18

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 (+)

Question 19

What other testing is indicative of lumbar radiculopathy

Answer 19

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+

Question 20

Surgical options in treating lumbar radiculopathy are

Answer 20

Laminectomy: Remove lamina allowing nerves more room
Disectomy: part of the lamina is removed to allow for a little extra room

Question 21

How do you decide between ice and heat

Answer 21

Ice has analgesic properties and numbs

Heat is soothing and helps reduce muscle spasms