low back pain

Question 1

causes of low back pain

Answer 1

mechanical (anatomic or functional problem): worsened by movement
nonmechanical (chemical irritation from inflammation or infection): pain at rest + movement
non-spinal:

Question 2

most common back pain

Answer 2

lumbar sprain/strain (lumbago):
tear in annulus fibrosus → leak fluid → inflammation, irritate lumbar roots
irritation of muscles, tendons, ligaments, joint capsule
inflammation of lower back → radiate to butt and hamstring
caused by twisting, lifting, overweight

Question 3

sciatica

Answer 3

herniated disk of lumbar region with impingement of nerve root (radiculopathy)
sharp/burning pain (radicular) along sciatic nerve dermatome
pain down back and BELOW knee (if not below knee = non-radicular)
pain worse with: valsalva, cough, bending forward
better with: lying down
positive SLR: sensitive

Question 4

risk factors for herniation

Answer 4

30-55 yo

Question 5

most common herniations

Answer 5

L4-L5

L5-S1

Question 6

acute neurological changes in structures supplied by sacral nerve roots: bowel and bladder dysfunction (urinary retention)
OR perineal anesthesia and BL leg pain = sciatica/weakness
+ SLR, reduced ankle sphincter tone, decreased ankle reflexes

Answer 6

cauda aquina syndrome - surgical emergency

Question 7

most common cause of cauda equina syndrome

Answer 7

large paracentral disk herniation

tumor

Question 8

degenerative changes in spine results in hypertrophy of facet joints + ligamentum flavum → diameter of spinal canal or neural outlets compromised (usually multiple levels)
low back and leg pain/weakness
pain worse with activity (pseudoclaudication), downhill walking, down stairs (extension of spine)
pain improves: bending over, shopping cart, squatting, lying, sitting
causes: degenerative arthritis, spondylolisthesis

Answer 8

spinal stenosis

Question 9

osteoporosis, neoplastic disease, elderly, chronic steroid use is risk factor for

Answer 9

vertebral compression fracture

Question 10

risk factor for osteoporosis

Answer 10

female
early menopause
smoking
sedentery lifestyle
chronic steroid use

Question 11

slow onset of back pain

Answer 11

spinal stenosis - degenerative

ankylosing spondylitis - rheumatologic

Question 12

chronic, constant dull low back pain

Answer 12

cancer

Question 13

electric shock pain - burning

Answer 13

irritated nerve or nerve root

Question 14

low back pain that radiates below knee

Answer 14

herniated disk
spinal stenosis
cauda equina syndrome

Question 15

pain in paraspinal muscles and radiates to butt

Answer 15

lumbar strain

Question 16

lumbar back pain + leg pain increases with activity

Answer 16

spinal stenosis

Question 17

stiffness decreases in 20-30 minutes

Answer 17

disk stiffness

Question 18

stiffness decrease in few hours

Answer 18

ankylosing spondylitis

Question 19

red flags for back pain

Answer 19

neuromotor deficit
unexplained fever
loss of B/B
suspect ankylosing spondylitis
osteoporosis
chronic CS use
immunosuppresion
alcohol abuse, IVDU
> 6 wks duration
cancer:
> 50 yo
personal hx of cancer
unexplained weight loss
pain worse at night
failed conservative therapy after 1 mo

Question 20

straight leg raising test

Answer 20

supine
sensitive for herniated disk - not specific
positive if radicular pain down leg occurs when leg is elevated between 30 and 60 degrees

Question 21

without red flags, treatment of acute low back strain/lumbago

Answer 21

conservative management for 4-6 wks (acetaminophen, NSAIDS, muscle relaxants - may cause sedation)
f/u in 1 month
early mobilization (no more than 2 days of bed rest), PT has short-term benefit
if no recovery after 1 mo or not candidate for surgery/epidural injection: MRI
if no spinal pathology: add PT, exercise
if unresolving herniated disk or spine pathology- refer to spine specialitist

Question 22

treatment of radiculopathy from herniated disk (sciatica)

Answer 22

conservative management (NSAIDS and/or muscle relaxant, activity as tolerated)
improve in 4-6 wks
if radicular radiating pain > 6 wks need MRI

Question 23

low back pain imaging

Answer 23

herniated disc, cauda equina, spinal stenosis: MRI
bony spinal pathology: CT
compression fracture, degenerative, cancer (follow up with MRI/ bone scan): xray

Question 24

bone scan

Answer 24

osteomyletitis
mets
occult fracture

Question 25

management of cauda equina syndrome

Answer 25

lumbar MRI

surgical decompression of entrapped cauda equina

Question 26

fever
direct vertebral tenderness
recent infection
IVDU

Answer 26

osteomyelitis
septic discitis
paraspinous abscess
epidural abscess

Question 27

management of infectious process of low back pain

Answer 27

CBC
ESR
blood culture, abscess culture
CSF
MRI
IV antibiotics +/- I&D

Question 28

diagnostic management of cancer: multiple myeloma, metastatic prostate, breast, lung

Answer 28

CBC
ESR
xray
if abnormal: get MRI and/or bone scan

Question 29

contralateral leg raise

Answer 29

specific for herniated disk

Question 30

treatment of spinal stenosis

Answer 30

conservative management: NSAIDS, PT, epidural CS

surgery: failed conservative or progressive neuro changes

Question 31

acute low back pain after lifting, bending, coughing
pain radiates BL anterior abdomen “girdle of pain”
T12-L2 fracture

Answer 31

vertebral compression fracture

Question 32

treatment of compression fracture

Answer 32

pain control
PT
calcitonin or bisphosphonates and treat underlying OP