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Clin Path II > Low Back > Flashcards

Low Back Flashcards

1
Q

What % of LBP is due to serious disease? What are the diseases?

A

3%
1% = local cancer or spinal infection
2% = referred pain from viscera (usually from GI, reproductive system or urinary)

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2
Q

What ancillary studies should you order if you suspect disease?

A
  • plain film - MRI, CT, or bone scan (looking for accumulation of black)
  • order ESR (or CRP) and CBC
  • if cancer or infection is suspected consider blood chemistry panel (calcium, ALP, protein)
  • if arthritic condition (anti-CCP, RF, ANA, HLA-B27)
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3
Q

Focusing on primary care patients, Von Korff (1996)
challenged the belief that __% of LBP resolved in
approximately __ weeks.

A

90%
3

He demonstrated that the course of back pain is
complex, with frequent recurrences.

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4
Q

About __% of patients continued to experience
_______________________ pain, either intermittently or
continuously at one year.

A

33%

Moderate or intense pain

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5
Q

About ___% reported important _______________
in the long term. Studies since then have
demonstrated similar results. (Chou 2010)

A

20%

functional limitations

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6
Q

What are the 5 clues for nerve root assessment?

A

History
- Leg pain (dermatomal? quality? More
intense than the LBP?)
- Dermatomal paresthesia

Physical Exam

  • Lumbar tension tests
  • Neurological deficits/abnormalities
  • Any other lumbar joint loading procedure that causes immediate leg sx
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7
Q

What are cauda equine syndrome signs and symptoms? What are important SN and SP?

A
  • Urinary RETENTION (90% sensitivity, 95% Assumed
    specificity, LR+ = 18; LR– = 0.1) and/or INCONTINENCE (high sensitivity)
  • Altered sensation in SADDLE DISTRIBUTION (75%
    sensitivity)
  • Diminished SEXUAL FUNCTION
  • Diminished anal SPHINCTER TONE (60-80% sensitivity)

*Other findings that may be there incidentally: Possible unilateral/, BILATERAL SCIATICA, positive SLR, other sensory/motor deficits (80% sensitivity for at least one of these).

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8
Q

What is the single best muscle test to check for an L5 here root compression (radiculopathy)? *****

A

Hip abduction (LR 95% CI, 1.3-84)

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9
Q

What is essential to chart about radiculopathy? What is optional to chart

A

Essential

  • where the pain is radiation
  • angle the leg was raised

Optional

  • quality of pain
  • Severity (1-10)
  • reproduces symptoms
  • other symptoms
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10
Q

If a SLR is a hard positive, what tests should you do next?

A

Confirm with

  • braggard (sensitivity 71%)
  • bowstring (sensitivity 69%)
  • bonnet (internal rotation and adduction) OR (seated SLR/ Bechterew)
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11
Q

If a SLR is a soft positive, what tests should you do next?

A

See if you can increase the pain into the foot

  • Maximum SLR
  • Seated SLR (bechterew)
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12
Q

If a SLR is a negative, what tests should you do next?

A
  • maximum SLR
  • assess hamstrings
  • assess lumbars, hip and SI
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13
Q

What angle of SLR is a positive?

A

Generally between 30-60 degrees

- >35-<45 may be more specific for herniation (especially non-contained)

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14
Q

Is seated SLR/Bechterew is positive, what test should you do next

A
  • seated bowstring (Deyerle’s)

- slump test (seated max SLR)

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15
Q

What nerve root is the Femoral stretch test testing? Which peripheral nerve? What is another name for this test? What does a positive tell you?

A

L2-4 and femoral nerve

“Reverse SLR”

  • may be positive for L4 hen SLR is negative
  • may be positive for foramina/far lateral disc herniation
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16
Q

What are extra-spinal causes of sciatica?

A
  • Piriformis syndrome
  • Pelvic/gynecologic conditions (INCLUDING ENDOMETRIOSIS)
  • Herpes zoster (shingles)
  • Diabetic neuropathy
  • HIV/Lyme disease neuropathy
  • Pregnancy/delivery (prolonged time in lithotomy position)
  • Trauma to nerve or surrounding structures (hip/pelvis/biceps femoris)
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17
Q

What is the common ancillary study ordered for extra-spinal causes of sciatica?

A

CATscan of the pelvis

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18
Q

What is the peak age for disc herniation in the lumbar spine? Where is the most common location?

A
  • Peak incidence at ages 30-55 years (other sources say 20-40)
  • 95-98% of clinically important lumbar disk herniations at L4-L5 or L5-S1
19
Q

Which lumbar disc herniations should definitely get and MRI?

A

Upper lumbar disc until L4???????

20
Q

After lumbar stenosis, fracture, and spondylolistheses have been ruled out, LUMBAR DISC HERNIATION accounts for about ___% of patients with sciatica

A

85%

21
Q

What are the clues for a disc herniation

A 
- Sx centralization with repetitive/sustained
loading  
- Decreased sagittal thoracolumbar ROM 
- Positive Valsalva
- Sitting poorly tolerated
- DeJeurine’s triad
- Flexion load sensitivity
- Sensitive to axial loading (e.g., dSLR) 
- Positive XSLR (well leg) 
- Mannequin sign*
22
Q

What are clues for disc derangement?

A 
Sx centralization with repetitive/sustained
loading  
- Decreased sagittal thoracolumbar ROM 
- Positive Valsalva
- Sitting poorly tolerated
- DeJeurine’s triad
- Flexion load sensitivity
- Sensitive to axial loading (e.g., dSLR)
23
Q

Which clues are for disc herniation but NOT for disc derangement?

A
  • Positive XSLR (well leg)

- Mannequin sign*

24
Q

What is the strongest single clue for disc herniation?

A

Positive XSLR (well leg)

25
Q

What are the earliest interventions for disc herniation/derangment? Post acute?

A

?

26
Q

What are medical treatments for herniated disc?

A

?

27
Q

What is the non surgical care prognosis?

  • ____% resolve without surgery
  • ____% recurrence of sciatica at 1 year
  • ____% of patients with muscle weakness recovered at 1 year
  • ____% of sensory deficits recovered at 1 year
  • _________ sometimes never recover
  • ____% of herniations shrink (MRI) by 1 year
A 
90
25
81
50
DTRs
76
28
Q

What are indications to order advanced imaging when there is a clinical diagnosis of lumbar disc herniation?

A
  • There are signs of cauda equina syndrome. This demands urgent referral or emergent referral if symptoms have come on rapidly. The patient is an immediate surgical candidate.
  • Progressive muscle weakness while undergoing conservative care.
  • If there is profound muscle weakness. Saal argues that profound muscle weakness may not be an absolute indication for surgery; these patients may respond to conservative care as well. (Saal 1996)
  • If a patient (or you) want a surgical consult.
  • If the patient does not respond as expected (i.e., about 50% improvement 4-6 weeks, 80-100% improvement at 3 months).
  • Suspected upper lumbar disc herniation. Since these are rare, the presence of a space occupying lesion should also be ruled out. (Greenhalgh 2006)
29
Q

What are non-lumbar indications for and MRI?

A

?

30
Q

What are the most common situations when to order plain films in low back cases?

A

?

31
Q

When a 70 year old patient has leg pain what should you think?

A

Stenosis

32
Q

What are causes of radiculopthy/radiculitis from the lumbar spine?

A
  • NR adhesion
  • fracture
  • spinal infection (especially abscess)
  • osteophyte compression (less common than in cervical spine)
33
Q

Patients over 60 ???? With back pain and neurological deficits (even if there is no leg pain) what should you be worried about?

A

Yellow/pink flag for tumor

34
Q

In patients with no nerve involvement, what is the ddx for lumbar?

A
  • disc (40%) based on double block chronic pain studies
  • facet (5-60%) based on double block chronic pain studies
  • sprain
  • strain
  • fracture (include spondylolisthesis/spondylisthesis)
35
Q

In patients with no nerve involvement, what is the ddx for pelvic?

A
  • sacroiliac joint (20%)
  • hip
  • pubic symphysis
36
Q

Where can groin pain come from/

A

Facet, SI, …..??????

37
Q

What are physical exam findings for facet syndrome?

A
  • extending up from flexion
  • active hyperextension,
  • passive extension (e.g., prone
    extension test),
  • and extension combined with rotation.
  • passive extension + rotation with overpressure (kemps)
  • palpation over facets is more painful than midline
  • usually restricted joint
  • walking least painful (helps to rule in)
  • sitting least painful position (helps rule in)
38
Q

Is kemps better at ruling out or in?

A
  • a negative Kemp’s test is better as evidence against facet syndrome (“pertinent negative”)
39
Q

What is the combination of positive findings that help diagnose facet syndrome?

A

If 3 or more of the following are positive (helps R/I):

  • Walking least painful activity,
  • sitting least painful position,
  • patient > 50,
  • pain onset was paraspinal,
  • positive ER (e.g., Kemp’s)
40
Q

What is the best evidence against a lumbar facet syndrome?

A
  • Pain centralization with repetitive or sustained spinal loading (Peterson 2017)
  • Lack of improvement with recumbency
  • No pain with extension + rotation (e.g.
    Kemp’s)
  • Evidence of radicular syndrome
41
Q

What are additional tests that are usually (but not always) negative in facet syndromes?

A
  • Valsalva maneuver (but could be positive in acute cases)

- Flexion biased loading tests

42
Q

What are Incidental findings that may be positive in a facet syndrome?

A

?

43
Q

How do you diagnose facet syndrome by a facet block?

A

?

Clin Path II (18 decks)

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