Low Back Pain

Question 1

90% lumbar ridiculous this involve what 2 roots?

Answer 1

L5

S1

Question 2

Define spondylosis

Answer 2

Degenerative arthritis affecting the spine

Question 3

Define spondylolisthesis

Answer 3

Thickening of ligamentum flavum

Question 4

Most common cause of spinal stenosis

Answer 4

Spondylosis

Spondylolisthesis

Question 5

Pain with ambulation localized to calf & distal lower extremity resolving when sitting / leaning forward

Answer 5

Pseudoclaudication
Neurogenic claudication
Spinal stenosis

All are synonyms.

Question 6

Inflammatory back pain

Answer 6

Morning stiffness
Improvement with exercise
Pain @ night
Extraskeletal Sx (ex: uveitis)

Question 7

Causes of low back pain that are not from the spine

Answer 7

Pancreatitis
Nephrolithiasis
Pyelonephritis 
AAA
Herpes zoster

Question 8

Clinical entitities associated with low back pain

Answer 8

1. Piriformis syndrome
2. SI joint dysfunction (controversial if this even exists)
3. Bertolotti syndrome (back pain in setting of transitional vertebra–a common finding on imaging: congenital anomaly with naturally occurring articulation / bony fusion btwn transverse process L 5 & sacrum. Treat as if they have nonspecific back pain. Whether/when surgery is indicated is not clear.

Question 9

Back pain radiating to buttock / lateral thigh / lateral calf / Dorsum of foot / great toe

Answer 9

L5 radiculopathy

Question 10

Back pain radiating into buttock, lateral/posterior thigh, posterior calf, lateral or plantar foot

Answer 10

S1 radiculopathy

Question 11

Sensory loss to lateral calf, Dorsum foot, web space btwn 1st & 2nd toe

Answer 11

L5 Radiculopathy

Question 12

Sensory loss to posterior calf, lateral or plantar aspect of foot

Answer 12

S1 radiculopathy

Question 13

Inguinal pain & numbness

Answer 13

L1 radiculopathy

Question 14

Achilles stretch reflex loss

Answer 14

S1 radiculopathy

Question 15

Semitendinosis/semimembranosus (internal hamstring) tendon loss of reflex

Answer 15

L5 Radiculopathy

Question 16

Waddell’s signs of inorganic back pain

Answer 16

Superficial tenderness
Straight leg test that improves with distraction
Pt over-reaction during physical exam
Nondermatomal sensory loss
Sudden giving way/jerky movements on motor exam
Inconsistency with spontaneous activity (getting dressed, etc)
Inconsistency on formal motor testing

Presence of multiple above components suggests psychogenic contribution to pain

Question 17

When should you get ESR/CRP in back pain eval

Answer 17

If you suspect infxn / malignancy

Question 18

Prevalence of disc herniation on MRI in asymptomatic ppl

Answer 18

Up to 70%

Question 19

% of MRI in asymptomatic ppl showing spinal stenosis

Answer 19

21% of pt > 60 y/o

Question 20

Significance of annular tears

Answer 20

No correlation with back pain in some studies

Question 21

Significance of schmorl’s node

Answer 21

Herniated nucleus pulposis into adjacent end plate
Associated with degenerative changes, but not an independent risk factor for back pain

Seen in 20% pt asymptomatic on MRI

Question 22

Significance of modic changes

Answer 22

Unknown significance

*specific signal changes in vertebral end plate & adj bone marrow on spine MRI

Question 23

MRI back with contrast

Answer 23

Distinguish scar from disc in pt with prior back surgery

Question 24

Suspect osteomyelitis in pt who cannot get MRI

Answer 24

Radionuclide scan

Question 25

Imaging indication low back pain

Answer 25

Severe / progressive Neuro deficit or when serious underlying conditions are suspected

Question 26

Pt > 50 y/o, failed trial of PT for LBP

Answer 26

Get imaging

Question 27

Ankylosing spondylitis risk factors that warrant imaging

Answer 27

Morning stiffness that improves with exercise Alternating buttock pain Awakening from back pain in second part of night

Question 28

Risk factors for compression Fx that warrant imaging

Answer 28

``` Osteoporosis Glucocorticoid Significant trauma F> 75 y /o M > 65 y/o ```

Question 29

Indication for MRI in radicular low back pain

Answer 29

L 4/5 or S1 radicular Sx or positive straight leg test who are candidates for injections or surgery

Question 30

Indications for MRI in spinal stenosis

Answer 30

Candidate for surgery

Question 31

Low back pain New urinary retention Fecal or urinary incontinence Saddle anesthesia

Answer 31

Emergent MRI: cauda Equina syndrome

Question 32

Low back pain | Progressive motor weakness / motor weakness at multiple levels

Answer 32

Emergent MRI

Question 33

Hx of CA, low back pain Initial w/u

Answer 33

Plain films + CRP/ESR if on DDx, but if high clinical suspicion, proceed directly to emergent MRI

Question 34

Concern for infxn in low back pain present, but not high suspicion

Answer 34

Plain films, CRP/ESR. If high suspicion, proceed directly to emergent MRI