Low Back Pain

Question 1

Cervical

Answer 1

C 1 - C7

Question 2

Thoracic

Answer 2

T 1 - T 12

Question 3

Lumbar

Answer 3

L 1 - L 5

Question 4

Sacrum

Answer 4

At bottom. Includes cocsic (sp?)

Question 5

Present with Acute Lower Back Pain

Answer 5

D/D: Kidney stone, slipped disc, pulled muscle

Question 6

Back pain is a SYMPTOM

Answer 6

It is not a diagnosis

Most are muscle-ligamentous (70%)
Disc degeneration (10%)
Disc herniation (4%)

Question 7

Central Disc Bulge

Answer 7

Nucleus and annulus “bulging” - compressing the cord

Question 8

Lateral Disc Herniation

Answer 8

Completely coming out. Impinging on the nerve

Question 9

Spondylolisthesis

Answer 9

Anterior or Posterior displacement in relation to the vertebrae below

Grading:
1 - up to 25%
2 - 25-50%
3 - 50-75%
4 - 75-100%
5 - >100% = spondylolisthesis

Question 10

Red Flag Things to Rule Out

Answer 10

(1) Cancer: unexplained weight loss

Question 11

Cauda Equina

Answer 11

S/S: bowel or bladder incontinence, urinary retention, progressive motor or sensory loss

Question 12

Fracture

Answer 12

Consider their age / Suffered some trauma

Question 13

Infection

Answer 13

Severe pain in the lumbar sign, history of IV drug use, or immunosuppression

Question 14

Herniated Disc / Bulging Disc

Answer 14

Back pain + Leg pain

Question 15

Spinal Stenosis

Answer 15

Walking hunched over, like shopping cart

Question 16

Initial Evaluation

Answer 16

(1) Mechanical / nonspecific back pain
(2) Back pain with neurologic compromise (radiculopathy / stenosis)
(3) Back pain due to other specific causes (neoplasm, infection, etc.)

Question 17

Clues for Neurologic Compromise

Answer 17

Burning/shooting pain that radiates past the knee

Pain worsening with coughing / valsalva maneuver –> suspect disk herniation

Pain relieved by flexion –> suggested stenosis

Sensory Changes

Neurogenic claudication

Weakness

Bowel / Bladder dysfunction (typically retention)

Question 18

Pain worsening with coughing / valsalva maneuver

Answer 18

Suspect Disk Herniation. Tear in the outer, fibrous ring of an intervertebral disk allows the soft, central portion to bulge out beyond the damaged outer rings. Tears are almost always postero-lateral (on the back of the sides).

Question 19

Pain relieved by flexion

Answer 19

Suggests stenosis. Stenosis is an abnormal narrowing in a blood vessel or other tubular organ or structure.

Flexion. bending movement that decreases the angle between the bones of the limb and joint.

Question 20

Range of motion

Answer 20

Flexion. Bend over to see how far they can go (40-60 degrees)

Extension. 20-35 degrees

Question 21

Straight leg test

Answer 21

Positive = radicular pain (between 30 and 70 degrees)

Crossed straight leg - more specific for disk herniation. (Raise the unaffected leg)

Check peripheral pulses to r/o vascular claudicaton

Question 22

98% of all disk herniations occur…

Answer 22

L4-5 & L5-S1

Question 23

L5 Motor

Answer 23

Test great toe dorsiflexion

Question 24

L5 sensory

Answer 24

Numbness in medial foot and 1st and 2nd toe webspace

Question 25

S1 motor

Answer 25

Test plantarflexion, although difficult to detect weakness until advanced disease process

Question 26

S1 sensory

Answer 26

Numbness in lateral foot & posterior calf

Question 27

S1 reflex

Answer 27

Unilateral absence of ankle jerk reflex (89% specifically)

Question 28

When to image?

Answer 28

Very often unnecessary.

Image when: history of significant trauma / neurologic symptoms / temperature above 100.4 / unexplained weight loss / history of cancer / Night pain (indicative of cancer) / Corticosteroid use (fractures) / Drug or alcohol abuse (increased disc space infection) / Suspect Ankylosing Spondylitis (inflammatory arthritis affecting the spine and large joints) / Suspicion of pars defect (stress fracture - often lower lumbar vertebrae (L5)

Question 29

MRI

Answer 29

The exact spinal and neurologic levels are unclear

When a pathological condition of the spinal cord or soft tissues suspected

When postoperative disk herniation is possible

When an underlying infectious or neoplastic causes is suspected

Question 30

CT Myelography

Answer 30

Nerve root pathology, particularly in patients with previous lumbar spinal surgery or with a metal fixation device in place.

Question 31

Tylenol

Answer 31

Reasonable 1st line