Lower Back Pain Flashcards
Epidemiology of Lower Back Pain (2)
28% suffer from LBP1
Back pain: second Most common disability and retirement from work force as of 2009
First 2 reasons why people will see their “doctor”
respiratory tract infection #2= MSK complaints
Lower back pain definition (4)
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
Lower Back pain Radiographically characterized by:
Disc space narrowing-vacuum phenomenon
Subchondral cyst formation
Osteophyte formation
Lumbar Spine X-Rays
AP and lateral L-S spine
Routine films
- Obliques
Look for spondylolysis (pars interarticularis fx) - Flexion and Extension
Look for unstable spondylisthesis
Indications for x-ray with lower back pain
Age > 50 years
No improvement after 6 weeks
History of trauma
Worrisome clinical finding such as very focal bone pain worse at nighttime
indications for MRI with lower back pain (2)
- After 6 weeks if presence of sciatica
- Interpret results with caution, as bulging discs are present on MRI or CT in more than half of
asymptomatic subjects. Correlate with physical exam.
Process of Central Spinal stenosis
Posterior disc bulge
Congenital narrow canal
Disc herniation
Osteoarthritis
Combination of any above
Spondylolysis, “scotty dog fx”
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.
neurologic screen for lower back pain
SLR (straight leg raising)
Manual muscle test (MMT),
Sensation to light touch
If no improvement in 4 to 6 weeks
Consider psychosocial factors
Nerve root compression with L2 will have?
Decreased hip flexor strength
Nerve root compression with L3 will have?
Decreased patellar reflex; sensation loss of the anterior thigh; weakness in quadriceps muscle; pain in the area of the anterior thigh
Nerve root compression with L4 will have?
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
Nerve root compression with L5 will have?
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
Nerve root compression with S1 will have?
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
What is cauda equina syndrome?
Urinary retention with overflow incontinence
Saddle anesthesia
paralysis without spasticity
Massive midline disc herniation or tumor compresses the descending lumbosacral nerve roots.
Risk Factors for Lower back pain
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
Red Flags for lower back pain
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
Different causes of lower back pain
. 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
Leg Pain Greater Than Back Pain: Herniated Nucleus pulposus with Lumbar Radiculopathy
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
Leg Pain Greater Than Back Pain: Spinal Stenosis:
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.
What is spinal stenosis
Narrowing of the spinal canal secondary to
hypertrophic changes of the bone
What are the 6 differential categories
Mechanical
Rheumatologic
Endocrine
Neurologic/psychiatric
Neoplastic
Referred
What are the rheumatologic differentials?
Ankylosing Spondylitis
Reiter’s Syndrome
Psoriatic Arthritis
Enteropathic Arthritis
DISH extra bones that develop along the vertebral bodies
PMR
Fibromyalgia
Acute, Subacute, Chronic phases of lower back pain
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
Management Recommendationsfor Acute LBP
If no red flags No investigation No referrals Reassure the patient Symptom control Avoid bed rest Return to activity
Exercise to prevent lower back pain
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
Treatments for lower back pain (unsure of effectiveness)
Acupuncture Back schools Epidural steroid injections Lumbar supports Massage Transcutaneous electrical nerve stimulation (TENS) Traction Trigger point injections Thermal therapy Ultrasound
Pharmacologic treatment for lower back pain
A. Anti-inflammatories
B. Tramadol
C. Opioids–> lack of response
D. Muscle relaxants
muscle relaxants
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
advantages of muscle relaxants
- analgesic
- adjunctive therapy
- Short-term use does not cause complications, blood dyscrasia, or kidney problems
- Reduce pain-causing muscle spasms, hypertonicity, and rigidity
disadvantages of muscle relaxants
dizziness
anticholinergic
sedation
abuse potential
