Low Back Pain Flashcards
what part of dic tears in a disk tear
outer part of disc (annulus) that occurs with aging
Jelly-like nucleus pushes against outer ring and puts pressure on nerves due to wear and tear
Dx?
disc herniation
Heel walk checks ___
Toe walk checks ____
heel L5
toe S1
what does a positive straight leg raise most likely indicate?
disc herniation
+ if pain moving from butt down to leg
disorder where vertebrae have too much mobility – slide on top of one another and compress spinal nerves
surgical tx?
Degenerative spondylolisthesis
spinal fusion
Space around spinal cords narrow and puts pressure on cord
Bone spurs grow to provide more support
dx? and most common cause
spinal stenosis
arthritis
imaging stude of choice for suspected disc herniation
MRI
CC with Degenerative spondylolisthesis
“pain and stiffness”
in spinal stenosis what symtpom reflects critical pressure on nerves
Weakened leg “foot drop”
pt presents w/ back “pain and stiffness” radiating from butt down to lower leg. he finds relief when leaning forward
dx?
spinal stenosis
what condition would require a laminectomy
spinal stenosis - removal of bone spurs
pt presents to clinic w/ abck pain. upon exam you notice he has a “round-back appearance” or a “bent over appearance”.
He notes the pain is bad with regular activities such as coughing or sneezing, twisting or reaching.
He reports pain is better when he lies down.
Dx?
surgical tx?
vertebral compression fx
kyphoplasty - baloon tamp into affected vertebrae first then cement
vertebroplasty - no baloon just cement into narrowed vertebrae
what condition could you dx w Dual energy x-ray absorptiometry (DEXA)
osteoporisis
in order for a pt w/ spinal stenosis to be a canidate for interspinous process devices they MUST:
have relief of butt and leg pain when leaning forward to be a candidate
also called “slipped disc”
disc herniation
lordosis vs kyphosis
lordosis - INWARD curvature at cervical and lumbar regions
kyphosis - OUTWARD curvature of thoracic spine “hump”
what is the cause for the inward curvature seen in hyperlordosis
Trunk flexors and hip extensors too weak to balance trunk ext and hip flex
results in lumbar spine overextended
types of kyphosis (3)
- Postural kyphosis à repeated poor posture seen in young F
- Scheuermann’s Kyphosis à vertebrae become wedged shape assoc. w/ scoliosis (kyphoscoliosis)
- Congenital kyphosis à vertebrae deformed during fetal development
Spine twisted / side-ways curvature “S” or “C” shape
scoliosis
scoliosis could be due to Dec in _______ causing a dec shock absorption resulting in a mis-shapen spine.
glycosaminoglycans____
what conditions are assoc w/ scoliosis
Neuromuscular disorers
cerebral paslsy
muscular dystrophy
what is a complication of SEVERE kyphosis/ scoliosis
Decreased space in thoracic cavity -> compresses heart -> and prevent lungs from fully expanding
- Shortness of breath
- Small thoracic cavity
- Inability to exercise
how can we determine the extent of a spinal deformity
measure cobb angle
angle between upper most and lower most vertebrae involved
what conditions are associated w/ lordosis and kyphosis
Deformative diseases:
- Ehlers-Danlos
- Marfans
- Osteoporosis
Injury:
- Compression Fx
- spondylolisthesis
- Misaligned vertebrae
Obesity
lordosis or kyphosis or scoliosis
kyphosis
lordosis or kyphosis or scoliosis
lordosis
lordosis or kyphosis or scoliosis
scoliosis
what condition results in the vertebrae become wedged shape
Scheuermann’s Kyphosis (kyphoscoliosis)
L2-L4 pain
Back radiating to anterior thigh (or medial lower leg)
L2-L4 sensory loss
anterior thigh
occasional medial lower leg
L2-L4 weakness
Hip flexion
Hip adduction
Knee extension
L4 - “squat and rise”
•Extension of quad
L2-L4 stretch reflex loss
patellar tendon
what nerve root is assoc w/ achilles tendon reflex
S1
What nerve root is assoc w/ Semitendinosus / semimembranosus (hamstring) tendon reflex
L5
L5 pain would be experienced:
Back radiating into
- Buttock
- lateral thigh
- lateral calf
- dorsum of foot
- Great toe
L5 sensory loss would be felt
Lateral calf
Dorsum of foot
Web space b/w 1st and 2nd toe
L5 weakness would be present during
Hip abduction
Knee flexion
Foot dorsiflexion
Toe extension and flexion
Foot inversion and eversion
“heel walking”
S1 would show pain in
Back radiating into
- buttock
- Lateral or posterior thigh
- Posterior calf
- Lateral or plantar foot
S1 sensory loss would be felt
Posterior calf
Lateral or plantar aspect of foot
S1 weakness during:
Hip extension
Knee flexion
Plantar flexion of foot + great toe
“toe walking”
differentiate S1, L4 and L5
L1 pain and sensation would be noticed in the ____ region with weakness during hip _____.
Inguinal
flexion
S2-S4 pain would present as
Sacral or buttock pain radiating into
- Posterior aspect of the leg
- or perineum
S2-S4 would have lack of sensation in
Medial buttock
Perineal
Perianal
S2-S4 would have weakness:
Minimal weakness
Urinary/fecal incontinence
Sexual dysfunction
Bulbocavernosus reflex loss:
S2-S4
identify the nerve roots responsible for the reflexes:
patellar tendon
Semitendinosus / semimembranosus (hamstring) tendon reflex
achillies tendon reflex
Bulbocavernosus (ankle wink)
patellar L4
hamstring - L5
achillies S1
bulbo S2-S4
most common nerve roots affected in disc herniation
L4-5 and L5-S1(90%)
in pts with a disc hernaiation they experience pain with prolonged ______ and usually experience more pain during (flexion / extension)
in pts w/ spinal stenosis they notice more pain after walking for a few minutes and notably the pain is felt greatest during (flexion / extension) are are relieved of pain when _____.
disc hern - prolonged sitting , FLEXION
spinal stenosis - EXTEND - lean forward
pt comes in complaining of low back pain.
they also note perianal numbness along w/ bowel or bladder incontinence.
What MUST you rule out
Cauda equina syndrome
study of choice to evaluation radicular sx (tingling, numbness, weakness, reflex loss)
MRI
is an inflammatory disease that, over time, can cause vertebral fusion
ankylosing spondylitis
pt presents to clinic complaining of low back pain:
you notice he is in the hunched forward position and says he is unable to breathe deeply, “stiffness when breathing”.
Dx?
what labs could we order to confirm dx?
HLA -B27
acute phase reactants (ESR, CRP)
linked to autoimmune conditions
what is usually the 1st presentation of spinal stenosis
•Neurogenic claudication symptoms with walking
what you expect to see on x-ray of a person w/ advanced anklyosing spondylitis
BAMBOO
You suspect a young male has anklyosing spondylitis - what imaging study could you order to evaluate the first site of inflammation?
MRI SI joint - bone marrow edema
a pt comes into clinic w low back pain. He perfers to sit bc of the pain
You note limited extension of lumbar spine, which reproduce the sx radiating down the legs.
the pain is worse w/ extension and alleviated by sitting/leaning forward.
Dx?
spinal stenosis
x-rap views when looking at low back pain
AP and lateral views of lumbar spine
NO oblique
Radiographs with _________ views may be helpful in patients for whom instability is a concern
Flexion-extension
MRI should be ordered (with or without) contrast when evaluating low back pain.
we should order ____ and ____ views.
w/o contrast
sagital and axial
Rx to tx low back pain
naproxen 500mg BID
flexeril 10mg QHS
oxycodone 5mg QHS PRN
how is naproxen dosed
10 NRF
naproxen 500mg
take 1 tablet BID w/ food for 5 days
how is flexeril dosed
7 NRF
flexeril 10mg
take 1/2 to 1 tablet PO QHS x 7 days
- Counsel pts NO drinking, driving, operative heavy machinery DOCUMENT
- Choice for spasm
how is oxycodone dosed
7
oxycodone 5mg
take 1 PO QHS PRN for back pain
