Low back pain Flashcards
Prevalence of low back pain world wide
18.3%
Criteria of acute low back pain
<12 weeks, high likelihood to resolve, little to no management required
Criteria of chronic low back pain
> 12 weeks, high risk for loss of function, treatment resistant
Risk factors for low back pain
lifting weight at work, smoking, depression, obesity, inactivity
Protective/preventive factors
regular exercise alone, education with exercise
Primary causes of low back pain
mechanical, visceral, nonmechanical
Etiologies of visceral low back pain
GI organs, abdominal aorta, renal, GU organs, endometriosis
Etiologies of nonmechanically induced low back pain
neoplasm, infection, inflammatory
Most common mechanical etiologies of low back pain
sprain/strain/overuse, piriformis syndrome, psoas syndrome, short leg syndrome
strain
injury to muscle
sprain
injury to ligament
pain pattern of sprain/strain
aching pain over injured structure
Etiology of piriformis syndrome
hypertonic piriformis muscle, nerve entrapment of sciatic n.
Origin piriformis
anterior sacrum
Insertion piriformis
greater trochanter
What muscles does the sciatic n. pass between?
superior gemellus and piriformis
pain pattern piriformis syndrome
aching/burning pain in gluteal region, paresthesia down posterior thigh
Etiology psoas syndrome
chronic hypertonicity of psoas muscle
origin psoas
T12-L4
Insertion psoas
greater trochanter
pain pattern psoas syndrome
patients will flex lumbar spine, pain originates at thoracolumbar region, worsens with extension
diagnosis of psoas syndrome
palpation of muscle, Thomas test, pelvic side shift resolves with manipulation
pelvic side shift
laterally translate innominate to test for preference
etiology of short leg syndrome
anatomic leg length discrepancy creates sacral base unleveling
pain pattern short leg syndrome
similar to overuse syndrome, pain in affected structures above low back
pelvic side shift for short leg syndrome
lateral translation of pelvis away from short leg
Treatment for short leg syndrome
heel lift therapy if discrepancy is >5mm or >1/5 inch
Heel lift therapy process
add 1/8 or 1/16 inch every 2 weeks
Prevalence of degenerative disc disease on radiographic finding
60-80% of adults > 49 yo
Etiology of degenerative disc disease
degeneration causes stress and inflammation of nociceptors
pain pattern of degenerative disc disease
nonspecific location
Degenerative disc disease pain worsens with…
bending forward, sneezing, coughing
Etiology spondylolysis
defect/stress factor of pars interarticularis
Pain pattern spondylolysis
asymptomatic, pain is common at L5 vertebrae
Spondylolysis pain worsens with…
hyperextension
Diagnostic Xray image of spondylolysis
Scotty dog
Etiology spondylolisthesis
anterior displacement of vertebrae secondary to bilateral pars defects
pain pattern spondylolisthesis
nonspecific
Risks of spondylolisthesis
age, bilateral spondylolysis
Spondylolisthesis pain worsens with…
extension and activity
Etiology of compression fracture
acute atraumatic fracture or chronic loss
pain pattern of compression fracture
asymptomatic or acute lower mid thoracic/thoracolumbar junction pain
Risks of compression fracture
age, osteoporosis, menopause, malignancy
Compression fracture worsens with…
sitting, spine extension, valsalva maneuver, movement
sciatica
symptom of numbness tingling pain in sciatic nerve distribution
Etiology spinal stenosis
narrowing of neural foramen or central canal
Pain pattern spinal stenosis
unilateral numbness and tingling, L4/L5/S1 nerve roots
Spinal stenosis pain worsens with…
standing and walking
Spinal stenosis pain improves with…
flexion, leaning forward, and sitting
pain pattern herniated disc
typically between L4-L5 (L5 nerve root) and L5-S1 (S1 nerve root)
pain pattern cauda equina syndrome
numbness and tingling in perineum, fecal/urinary incontinence, radicular numbness tingling or weakness
Delayed treatment of cauda equina will lead to
permanent incontinence and disability
Red flag symptoms of low back pain
progressive lower extremity weakness, saddle anesthesia/loss of bladder and bowel control, deep bone pain or unexplained weight loss, and fever/chills
When should imaging not be ordered?
low back pain within first 6 weeks unless there is progressive neuro deficit
Conservative methods of back pain management
reassurance, continue activity, avoid bed rest, muscle relaxers, antidepressants, physical therapy, OMM
Greenman’s dirty half dozen
muscle imbalance, lumbar spine type 2 dysfx, short leg, sacral extension dysfx, innominate shear
Invasive treatments for back pain
epidural injection, facet injection, radiofrequency ablation, decompression or fusion surgery
Lumbar prone direct long lever–Rotation
stand opposite of PTP, grasp ipsilateral pelvis around ASIS; rotate lumbars sequentially up slightly superior to SD, hypothenar or pisiform on PTP and thrust after exhalation
Lumbar longer lever–Rotation
stand opposite PTP, grasp ipsi leg above knee, rotate lumbars superior to SD, hand on named vertebra or one below SD
Lumbar direct rotational-sidebending
localize sidebending by pulling on leg–posterior and lateral for type I and towards floor for type 2
Prolotherapy
chemical or mechanical irritant to induce growth and formation of new fibro-elastic connective tissue
Clinical suggestions of sacral base unleveling
uneven medial malleoli, knee height inequity
Expected compensations in short leg syndrome
Lumbar spine bent away from short side, innominate rotated anterior on side of dysfx, superior pelvic sheer or posterior rotation of long leg, foot on long leg pronated with internal rotation
X-ray measurement on postural scan for short leg syndrome
sacral declination–line of eburnation
