Lower Back Pain

Question 1

Epidemiology of Lower Back Pain (2)

Answer 1

28% suffer from LBP1

Back pain: second Most common disability and retirement from work force as of 2009

Question 2

First 2 reasons why people will see their “doctor”

Answer 2

respiratory tract infection
#2= MSK complaints

Question 3

Lower back pain definition (4)

Answer 3

Pain felt in your lower back.

Spine, muscles, nerves, ligaments or other structures.

Can radiate from other areas.

LBP can be acute or chronic as defined by
3 months or longer

multifactorial biopsychosocial pain

Question 4

Lower Back pain Radiographically characterized by:

Answer 4

Disc space narrowing-vacuum phenomenon
Subchondral cyst formation
Osteophyte formation

Question 5

Lumbar Spine X-Rays

Answer 5

AP and lateral L-S spine
Routine films

2. Obliques
   Look for spondylolysis (pars interarticularis fx)
3. Flexion and Extension
   Look for unstable spondylisthesis

Question 6

Indications for x-ray with lower back pain

Answer 6

Age > 50 years
No improvement after 6 weeks
History of trauma
Worrisome clinical finding such as very focal bone pain worse at nighttime

Question 7

indications for MRI with lower back pain (2)

Answer 7

1. After 6 weeks if presence of sciatica
2. Interpret results with caution, as bulging discs are present on MRI or CT in more than half of
   asymptomatic subjects. Correlate with physical exam.

Question 8

Process of Central Spinal stenosis

Answer 8

Posterior disc bulge

Congenital narrow canal

Disc herniation

Osteoarthritis

Combination of any above

Question 9

Spondylolysis, “scotty dog fx”

Answer 9

This condition occurs in childhood and has risk factors of football players and in girls who are gymnasts. This lysis can eventually result in spondylolithesis where one vertebra slips forward on another.

Risk factors associated with development of this condition in non-athletes include:
Aging-obesity, lordotic angle and pelvic inclination were found to be individual risk factors for women and obesity the major risk factor for men for Lumbar Spondylolysis.

Question 10

neurologic screen for lower back pain

Answer 10

SLR (straight leg raising)
Manual muscle test (MMT),
Sensation to light touch

If no improvement in 4 to 6 weeks

Consider psychosocial factors

Question 11

Nerve root compression with L2 will have?

Answer 11

Decreased hip flexor strength

Question 12

Nerve root compression with L3 will have?

Answer 12

Decreased patellar reflex; sensation loss of the anterior thigh; weakness in quadriceps muscle; pain in the area of the anterior thigh

Question 13

Nerve root compression with L4 will have?

Answer 13

Sensory loss of the anterior lateral or medial foot; possible decreased patellar tendon reflex; weakness of the quadriceps; pain in the area of the anterior leg

Question 14

Nerve root compression with L5 will have?

Answer 14

Sensory loss in the dorsum of the foot and great toe; weakness of the anterior tibialis, great toe (extensor hallicus longus), and hip abductors; pain down the side of the leg

Question 15

Nerve root compression with S1 will have?

Answer 15

Decreased Achilles’ reflex; sensory loss of the lateral foot and the small toe; weakness of the gastrocnemius, gluteus maximus, plantar flexor, and great toe; pain down the back of the leg into the bottom or side of the foot

Question 16

What is cauda equina syndrome?

Answer 16

Urinary retention with overflow incontinence

Saddle anesthesia

paralysis without spasticity

Massive midline disc herniation or tumor compresses the descending lumbosacral nerve roots.

Question 17

Risk Factors for Lower back pain

Answer 17

Work in construction 
Heavy lifting 
Lots of bending and twisting
Whole body vibration
Have bad posture 
Pregnant 
Over age 30 
Smoke, don't exercise, overweight
Have arthritis or osteoporosis
Have a low pain threshold
Feel stressed or depressed

Question 18

Red Flags for lower back pain

Answer 18

Age >50
Significant trauma
Neurologic deficit
Weight loss (unexplained)
Substance abuse
Ankylosing spondylitis
Night pain
Malignancy Hx
Systemic steroids 
Fever (>100º F)
Persistent pain
Compensation issues
Increased pain when recumbent
Bowel and bladder dysfunction

Question 19

Different causes of lower back pain

Answer 19

.  Idiopathic	70%
	“Lumbar strain/sprain”	
2.  Degenerative disks and facets	10%
3.  Herniated disks	2% to 4%
4.  Spinal stenosis	 3%
5.  Osteoporotic compression fracture	 4%
6.  Spondylolisthesis

Question 20

Leg Pain Greater Than Back Pain: Herniated Nucleus pulposus with Lumbar Radiculopathy

Answer 20

Referred neurogenic pain in the distribution of a lumbar (or cervical) nerve root or roots, with or without associated numbness, weakness, or loss of reflexes

• The irritating inner disc material (nucleus pulposus) escapes the disc and impinges an adjacent nerve root
• Positive straight leg raise
• Pain or paresthesia that radiates in a dermatomal pattern typically down the posterior or lateral leg and past the knee
• Loss of the respective reflex
• Symptoms worse with sitting, better with recumbency or standing

Question 21

Leg Pain Greater Than Back Pain: Spinal Stenosis:

Answer 21

Pseudoclaudication
– Canal is wider when seated and becomes more narrow with standing

– Therefore the patient can walk a farther distance and remain
standing for a longer period if bent forward such as when pushing a shopping cart
– Symptoms in the legs when standing upright are often nondescript

• Legs feel “heavy” or “like rubber”
• Pain can be in a dermatomal distribution
• The clinical term of “spinal stenosis” is not used based on imaging
only. There must be symptoms of leg or buttock discomfort worse
on standing and improved on sitting.

Question 22

What is spinal stenosis

Answer 22

Narrowing of the spinal canal secondary to

hypertrophic changes of the bone

Question 23

What are the 6 differential categories

Answer 23

Mechanical

Rheumatologic

Endocrine

Neurologic/psychiatric

Neoplastic

Referred

Question 24

What are the rheumatologic differentials?

Answer 24

Ankylosing Spondylitis

Reiter’s Syndrome

Psoriatic Arthritis

Enteropathic Arthritis

DISH extra bones that develop along the vertebral bodies

PMR

Fibromyalgia

Question 25

Acute, Subacute, Chronic phases of lower back pain

Answer 25

Acute phase: up to 4 weeks
Control pain and minimize activity
but not bed rest

Subacute phase: 4 to 12 weeks
Control pain and maximize activity

Chronic: >3 months’ duration
Multidisciplinary interventions

Question 26

Management Recommendationsfor Acute LBP

Answer 26

If no red flags 
No investigation 
No referrals
Reassure the patient
Symptom control
Avoid bed rest
Return to activity

Question 27

Exercise to prevent lower back pain

Answer 27

There is strong evidence that exercise helps prevent LBP:
Strengthens the back muscles and increases trunk flexibility

Increases blood supply and thus minimizes injury and enhance repair

Improves mood

Has a positive effect on the perception of pain

Question 28

Treatments for lower back pain (unsure of effectiveness)

Answer 28

Acupuncture 
Back schools 
Epidural steroid injections 
Lumbar supports 
Massage
Transcutaneous electrical nerve stimulation (TENS) 
Traction
Trigger point injections
Thermal therapy
Ultrasound

Question 29

Pharmacologic treatment for lower back pain

Answer 29

A. Anti-inflammatories
B. Tramadol
C. Opioids–> lack of response
D. Muscle relaxants

Question 30

muscle relaxants

Answer 30

Muscle relaxants may promote healing by facilitating movement
Muscle relaxants may reduce the length of the acute stage
May prevent the development of an acute injury into a chronic condition
Effective alone or in combination with NSAIDs

Question 31

advantages of muscle relaxants

Answer 31

• analgesic
• adjunctive therapy
• Short-term use does not cause complications, blood dyscrasia, or kidney problems
• Reduce pain-causing muscle spasms, hypertonicity, and rigidity

Question 32

disadvantages of muscle relaxants

Answer 32

dizziness
anticholinergic
sedation
abuse potential