Low Back Flashcards
What % of LBP is due to serious disease? What are the diseases?
3%
1% = local cancer or spinal infection
2% = referred pain from viscera (usually from GI, reproductive system or urinary)
What ancillary studies should you order if you suspect disease?
- 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)
Focusing on primary care patients, Von Korff (1996)
challenged the belief that __% of LBP resolved in
approximately __ weeks.
90%
3
He demonstrated that the course of back pain is
complex, with frequent recurrences.
About __% of patients continued to experience
_______________________ pain, either intermittently or
continuously at one year.
33%
Moderate or intense pain
About ___% reported important _______________
in the long term. Studies since then have
demonstrated similar results. (Chou 2010)
20%
functional limitations
What are the 5 clues for nerve root assessment?
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
What are cauda equine syndrome signs and symptoms? What are important SN and SP?
- 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).
What is the single best muscle test to check for an L5 here root compression (radiculopathy)? *****
Hip abduction (LR 95% CI, 1.3-84)
What is essential to chart about radiculopathy? What is optional to chart
Essential
- where the pain is radiation
- angle the leg was raised
Optional
- quality of pain
- Severity (1-10)
- reproduces symptoms
- other symptoms
If a SLR is a hard positive, what tests should you do next?
Confirm with
- braggard (sensitivity 71%)
- bowstring (sensitivity 69%)
- bonnet (internal rotation and adduction) OR (seated SLR/ Bechterew)
If a SLR is a soft positive, what tests should you do next?
See if you can increase the pain into the foot
- Maximum SLR
- Seated SLR (bechterew)
If a SLR is a negative, what tests should you do next?
- maximum SLR
- assess hamstrings
- assess lumbars, hip and SI
What angle of SLR is a positive?
Generally between 30-60 degrees
- >35-<45 may be more specific for herniation (especially non-contained)
Is seated SLR/Bechterew is positive, what test should you do next
- seated bowstring (Deyerle’s)
- slump test (seated max SLR)
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?
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
What are extra-spinal causes of sciatica?
- 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)
What is the common ancillary study ordered for extra-spinal causes of sciatica?
CATscan of the pelvis
What is the peak age for disc herniation in the lumbar spine? Where is the most common location?
- 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
Which lumbar disc herniations should definitely get and MRI?
Upper lumbar disc until L4???????
After lumbar stenosis, fracture, and spondylolistheses have been ruled out, LUMBAR DISC HERNIATION accounts for about ___% of patients with sciatica
85%
What are the clues for a disc herniation
- 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*
What are clues for disc derangement?
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)
Which clues are for disc herniation but NOT for disc derangement?
- Positive XSLR (well leg)
- Mannequin sign*
What is the strongest single clue for disc herniation?
Positive XSLR (well leg)
What are the earliest interventions for disc herniation/derangment? Post acute?
?
What are medical treatments for herniated disc?
?
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
90 25 81 50 DTRs 76
What are indications to order advanced imaging when there is a clinical diagnosis of lumbar disc herniation?
- 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)
What are non-lumbar indications for and MRI?
?
What are the most common situations when to order plain films in low back cases?
?
When a 70 year old patient has leg pain what should you think?
Stenosis
What are causes of radiculopthy/radiculitis from the lumbar spine?
- NR adhesion
- fracture
- spinal infection (especially abscess)
- osteophyte compression (less common than in cervical spine)
Patients over 60 ???? With back pain and neurological deficits (even if there is no leg pain) what should you be worried about?
Yellow/pink flag for tumor
In patients with no nerve involvement, what is the ddx for lumbar?
- 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)
In patients with no nerve involvement, what is the ddx for pelvic?
- sacroiliac joint (20%)
- hip
- pubic symphysis
Where can groin pain come from/
Facet, SI, …..??????
What are physical exam findings for facet syndrome?
- 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)
Is kemps better at ruling out or in?
- a negative Kemp’s test is better as evidence against facet syndrome (“pertinent negative”)
What is the combination of positive findings that help diagnose facet syndrome?
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)
What is the best evidence against a lumbar facet syndrome?
- 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
What are additional tests that are usually (but not always) negative in facet syndromes?
- Valsalva maneuver (but could be positive in acute cases)
- Flexion biased loading tests
What are Incidental findings that may be positive in a facet syndrome?
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How do you diagnose facet syndrome by a facet block?
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