Lower Back Pain Flashcards
In the lying position, the pressure on the discs is ____ kg
when standing or walking ___ kg
when sitting ___ kg
when lifting a load ____ kg
In the lying position, the pressure on the discs is 25-75 kg
when standing or walking 100 kg
when sitting 135-180 kg
when lifting a load 275 kg
List risk factors for lower back pain (5)
- repetitive actions
- vibrations
- cigarettes (osteoporosis)
- massive thickness
- major skeletal abnormalities
degenerative changes caused by disc aging
Major skeletal abnormalities leading to lower back pain (3)
- scoliosis >40%
- spinal stenosis
- ankylosing spondylosis
Degenrative changes caused by disc aging (2) that lead to lower back pain
- descrease nucleus pulposus
- thickening of the annulus fibrosus
Anamnesis for lower back pain
- mechanism of pain/injury
- duration, quality, and spread of pain
- precipitating factors
- facilitating and aggravating factors
- previous history of back problems
- other diseases/injuries
- medicines
What is relationship between history of malignancy and back pain?
In patients with a personal history of cancer, new back pain should be considered malignant until proven otherwise
Most commong cause of low back pain according to age:
>50
>65
>70
<40
> 50 malignancy
65 abdominal aortic aneurysm in a male current or former smoker
70 compression fracture with or without trauma
<40 ankylosing spondylitis
What could be a possible reason for low back pain for someone who has previously been treated with corticosteroids for more than 1 month?
Compression fracture
What could be a possible reason for low back pain for someone who uses injection drugs or has a current infection?
osetomyelitis or paraspinal abscess
what is the cause of pain: low back pain, but pain remains above the knee
hip pathlogy
what is the cause of pain: low back pain, but pain radiates down the leg below the knee
sciatica (irritation or compression of the L4-L5, S1, nerve roots, usually from a disk herniation)
what is the cause of pain: low back pain, but pain is localized in the abdomen or pelvis
visceral source
diagnosis: low back pain, but pain is electrical or shock-like
disk herniation
diagnosis: low back pain, pain is constant and nocturnal
malignancy when worse with rest
mechanical when improved with rest
low back pain, pain is colicky
referred pain from a visceral organ
pain with tearing/ripping quality
aortic dissection
diagnosis of cyclical low back pain
endometriosis
low back pain that has been persisten and progressive for over 1 month, older pt
malignancy in older pt
low back pain that has been persistent an progressive for over 3 months, younger pt
ankylosing spondylitis
low back pain worse in the morning and associated with morning stiffness
ankylosing spondylitis
pain in the legs with standing that increases with cough or walking
neurogenic claudication from spinal stenosis
low back pain that imrpoves with forward bending or sitting
spinal stenosis or spondylolisthesis
low back pain that improves with excersice
ankylosing spondylitis
low back pain that worsesn with bending forward or sitting
disk herniation
if there is some connection to eating pattern (improves/worsens after eating, vomiting, nausea), low back pain is due to
GIT
low back pain + fever
osteomylitis, malignancy, infection related to intra-abdominal or pelvic eitology
physical exam of low back pain includes: (4)
- inspection
- palpation
- specific tests
- neurologic examination
inspection during physical exam of low back pain include:
- walk
- position
- scoliosis
- kyphosis
- lordosis
palpation of low back pain during physical exam includes
- paravertebral musculature
- spiny appendages
- sacroiliac joints
- abdominal palpation
List specific tests for low back pain (4)
- movement in 4 directions
- leg lift
- PAtrics - FABRE test
- Valsava maneuver
Describe test movement in 4 directions
anteflexion, retroflexion, lateroflexion, rotation
ICD-10 for low back pain
M54. 5, referred to as “lumbago”
What does “FABRE” stand for?
F - FLEXION of the hip and knee on the painful leg
AB - ABDUCTION of the leg
ER - EXTERNAL ROTATION of the knee (heel to the knee of the healthy leg)
E - EXTENSION (fix the opposite hip and press the knee)
FABRE test: back pain
compression fracture
FABRE test: pain in the sacroilliac joint
pathology in that joint
FABRE: hip pain
degenrative changes in the hip joint
FABRE: pain spreads towards the toes
radiculopathy
FABRE: no pain
other etiology
Neurological exam of low back pain consists of
- position
- muscle strength
- sensibility
- reflexes
what reflexes do we check with low back pain
- anal
- cremasteric
- patelar
- achilles
Describe: L5-S1 disc herniation (S1 nerve root): (50% of cases)
Pain radiation: into posterior thigh, posterior and lateral calf, and heel
Sensory deficit: posterior calf, and lateral aspect of foot
Motor deficit: plantar flexors – have patient walk on toes
Reflex deficit: ankle
Describe: L5-S1 disc herniation (S1 nerve root): (50% of cases)
pain radiation, sensory deficit, motor deficit, reflex deficit
Pain radiation: into posterior thigh, posterior and lateral calf, and heel
Sensory deficit: posterior calf, and lateral aspect of foot
Motor deficit: plantar flexors – have patient walk on toes
Reflex deficit: ankle
Describe : L4-5 disc herniation (L5 nerve root): (40% of cases)
pain radiation, sensory deficit, motor deficit, reflex deficit
Pain radiation: into lateral thigh, anterior calf and dorsum of the foot, +/- great toe
Sensory deficit: anterior calf, dorsum and medial aspect of foot, first web space, +/- great toe
Motor deficit: dorsiflexors - have patient walk on heels, or dorsiflex great toe against resistance
Reflex deficit: none
Describe: disc herniation (L4 nerve root): (10% of cases)
pain radiation, sensory deficit, motor deficit, reflex deficit
Pain radiation: into lateral and anterior thigh, medial calf, medial foot, +/- great toe
Sensory deficit: medial calf and foot, +/- great toe
Motor deficit: Quadriceps
Reflex deficit: knee
should we order imaging for sciatica according to NICE2016
let specialists decide that, do not order it routinely
Treatment of low back pain
NON-PHARMACOLOGICAL (CORRECT ATTITUDE AND POSTURE)
PHARMACOLOGICAL (NSAIDs, muscle relaxant, aggravating activities)
If the symptoms persists beyond 4 weeks, physical therapy should be considered; MRI (if radicular symptoms become bothersome)
Steps for pharmacological therapy of low back pain
- NSAIDS (Take into account GIT, liver, cardiotenal toxicity) at lowest effective dose
- weak opioids (with ot without paracetamol)
- do not offer paracetamol alone
- do not offer: opioids for chronic pain, SSRI, SNRI or TCA, gabapentinoids or antiepileptics
low back pain red flags ( a lot of them, just read)
Progressive neurologic deficit
Recent bowel or bladder dysfunction
Saddle anesthesia
Traumatic onset
Age > 50
Male with diffuse osteoporosis or compression fracture
Cancer history
Insidious onset
No relief at bedtime or worsens when supine
Constitutional symptoms (e.g. fever, weight loss)
Hx UTI/other infection, IV drug use, TB exposure
Immune suppression, Steroid use history
Previous surgery
