Low Back Pain Flashcards
Acute vs Chronic Low Back Pain
Acute low back pain is defined as activity intolerance due to low back pain or back-related leg symptoms of less than 3 months duration
Chronic > 3 months
Radiology
90% back pain resolves in 1 month w/o medical tx
Imaging should be delayed 1-2 months in pts with nonspecific low back pain and no red flags
Causes of Back Pain
Mechanical - poor ergonomics: lifting, carrying, bending, sitting; fractures, scoliosis, Spondylolisthesis/Spondylolysis(most common causes)
Non-Mechanical - neoplasms, infections, inflammatory: discitis, osteomyelitis, varicella zoster, abscess
Visceral - dz of pelvic organs, renal dz, aortic aneurysm, GI disorders: ulcers, pncrtitis, cholecystitis
Spondylolisthesis
Spondylolysis
Spondylolisthesis - forward displacement of a vertebra, especially the fifth lumbar vertebra, most commonly occurring after a break or fracture
Spondylolysis - defect in the pars interarticularis of the vertebral arch
Approach to Dx
Determine if source is neurological or orthopedic
Identify pain generators
Eliminate confounders
ROM flexibility
Ambulation and gait
Segmental motion
Differentiating between tolerance, opioid-induced hyperalgesia and disease progression
Functionality
Psychosocial issues
Kinetic chain - problems elsewhere r/t back pain
Clinical Presentation - Lumbarsacral Strain
Minimal discomfort immediately and > 12-36 hours after as soft tissue swell
Pain is located in back, buttocks or in one or both thighs
Aggravated by standing or flexion and is relieved by rest or reclining
Clinical Presentation - Herniated Disc
Characterized by radicular pain described as sharp or shooting, electrical pain
Paresthesia or numbness may occur in sensory distribution of nerve root
Deep tendon reflexes are absent or depressed in distribution of nerve
Muscular weakness and atrophy may result
Most common disk ruptures affect L5 or S1 nerve roots
Patients begin to improve in 6 weeks time, 2/3 complete recovery in 6 months
Clinical Presentation - Spondylolysis/Spondylolisthesis
Occurs from stress fx Can be familial Neuro exam normal Tight hamstring Hyperextension (back bending) produces L5 pain
Clinical Presentation - Degenerative Process
Have gradual onset of pain accompanied by morning stiffness or stiffness after prolonged immobility
Clinical Presentation - Spinal Stenosis
Middle to older adults
Gradual onset of bilateral neurogenic claudicating (pain, paresthesias and weakness) when walking
Usually relieved when patient flexes lumbar spine or sits
Severe cases may have bowel or bladder disturbances (cauda equinina)
Clinical Presentation - Osterparotic Compression Fx
Chronic pain and fatigue in mid-back with signs of spinal deformity or loss of height
Kyphosis
Exam
Hx: onset, trauma/injury, OP, CA, prior imaging
ROS: unexplained fevers, gyn problems, cardiac probs, aortic aneurysm
PE
XRay vs MRI
Electro-diagnostic studies - EEG, EMG
Consult and Referral – Orthopedics, Physiatrist, Pain Management specialist, Neurosurgery
PE
Observation of appearance or gait and independent ability to flex and extend leg at hip and knee
Vital Signs: Temperature
Observation and Palpation of spine alignment
ROM
Abdominal exam
Pelvic exam
Digital rectal and check sensation of perineum or stability of coccyx if fell
Palpate ischial tuberosity and greater trochanter to rule out bursitis
Perform Traction Maneuvers: Straight leg raise (SLR), Gross leg raise, Yeoman
Check for Malingering: Overreaction, Axial loading, pelvic rotation, distracted SLR
Neurological Examination: Determine pain distribution, motor strength, dorsiflexion of great toe, circumferential calf measurement, deep tendon reflex, observe for nonanatomical motor or sensory regional distributions
Assess legs and feet to differentiate spinal stenosis from vascular insufficiency
Measuring chest expansion <2.5 may indicate
ankylosis spondylitis
Dx Tests
X-rays are useful in only a minority of cases (spinal stenosis not diagnostic but will show degenerative changes)
Labs- CBC, ESR, UA
MRI – best at imaging soft tissue (herniated disc, tumors, spinal stenosis)
CT – is better at imaging bone (osteoarthritis)
Bone Scan (osteomyelitis, neoplasm, or occult- fracture)
Electromyography (EMG) to determine level of nerve root
Red Flags - Possible Fx
Trauma
Steroid use
> 70 years
Possible Tumors or Infection
>50 <20
History of cancer
Fever, chills, unexplained weight loss
Recent infection, IV drug use, abuse, immunosuppression
Pain worsens when supine, nighttime, fails to improve
