low back pain Flashcards
causes of low back pain
mechanical (anatomic or functional problem): worsened by movement
nonmechanical (chemical irritation from inflammation or infection): pain at rest + movement
non-spinal:
most common back pain
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
sciatica
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
risk factors for herniation
30-55 yo
most common herniations
L4-L5
L5-S1
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
cauda aquina syndrome - surgical emergency
most common cause of cauda equina syndrome
large paracentral disk herniation
tumor
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
spinal stenosis
osteoporosis, neoplastic disease, elderly, chronic steroid use is risk factor for
vertebral compression fracture
risk factor for osteoporosis
female early menopause smoking sedentery lifestyle chronic steroid use
slow onset of back pain
spinal stenosis - degenerative
ankylosing spondylitis - rheumatologic
chronic, constant dull low back pain
cancer
electric shock pain - burning
irritated nerve or nerve root
low back pain that radiates below knee
herniated disk
spinal stenosis
cauda equina syndrome
pain in paraspinal muscles and radiates to butt
lumbar strain
lumbar back pain + leg pain increases with activity
spinal stenosis
stiffness decreases in 20-30 minutes
disk stiffness
stiffness decrease in few hours
ankylosing spondylitis
red flags for back pain
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
straight leg raising test
supine
sensitive for herniated disk - not specific
positive if radicular pain down leg occurs when leg is elevated between 30 and 60 degrees
without red flags, treatment of acute low back strain/lumbago
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
treatment of radiculopathy from herniated disk (sciatica)
conservative management (NSAIDS and/or muscle relaxant, activity as tolerated)
improve in 4-6 wks
if radicular radiating pain > 6 wks need MRI
low back pain imaging
herniated disc, cauda equina, spinal stenosis: MRI
bony spinal pathology: CT
compression fracture, degenerative, cancer (follow up with MRI/ bone scan): xray
bone scan
osteomyletitis
mets
occult fracture
management of cauda equina syndrome
lumbar MRI
surgical decompression of entrapped cauda equina
fever
direct vertebral tenderness
recent infection
IVDU
osteomyelitis
septic discitis
paraspinous abscess
epidural abscess
management of infectious process of low back pain
CBC ESR blood culture, abscess culture CSF MRI IV antibiotics +/- I&D
diagnostic management of cancer: multiple myeloma, metastatic prostate, breast, lung
CBC
ESR
xray
if abnormal: get MRI and/or bone scan
contralateral leg raise
specific for herniated disk
treatment of spinal stenosis
conservative management: NSAIDS, PT, epidural CS
surgery: failed conservative or progressive neuro changes
acute low back pain after lifting, bending, coughing
pain radiates BL anterior abdomen “girdle of pain”
T12-L2 fracture
vertebral compression fracture
treatment of compression fracture
pain control
PT
calcitonin or bisphosphonates and treat underlying OP
