Lower Back Pain Flashcards
How long does it take for most lower back pain problems to resolve?
2 to 4 weeks
97% of all back pain
Mechanical
Most common mechanical causes of back pain
Lumbar strain- 70%
Degenerative joint changes- 10%
Herniated disc- 4%
Risk of low back pain
Prolonged sitting Deconditioning Poor lifting techniques Repetitive lifting Congenital causes Obesity
Red flags
Fever Weight loss Pain at night Bowel or bladder issues Neurological symptoms
Classic disc herniation
Worse with sitting or bending Better when laying or standing Others - Radiation down leg - Paresthesia - Weakness
Night pain or pain at rest is a red flag for
Cancer
Hx of IV drug use is a red flag for
Infection
Major muscle weakness or foot drop is red flag for
Significant herniated nucleus pulposus
Chance of returning to work if out for 6 months? At 2 years?
50%
Almost 0
Systematic order of performing a physical exam for back pain
Standing
Sitting
Supine
Basic components
Inspection
Palpation
ROM
Restriction or pain with flexion indicate
Herniation
OA
Muscle spasm
Pain with extension
Degenerative disease
Spinal stenosis
Pain on same side as lateral motion
Bone pathology (OA or compression)
Pain on opposite side as lateral motion
Muscle strain
Difficulty walking on heal
L5 herniation
Difficulty walking on toe
S1 herniation
Pain is reduced while squatting
Central spinal stenosis
(+) tripod sign
- Modified straight leg test
Structural disease
In what position should you do a neurological exam
- Reflexes
- Strength
- Sensation
Sitting
What are the main nerve roots to focus on
L4 through S1
Great toe
L5
Lateral malleolus and posterolateral foot
S1
4+ gradding on reflexes
Clonus
Decreased patella reflex
L3 to L4 impingement
Decreased achilles reflex
L5 to S1 impingement
Hyper-reflexia
Upper motor neuron sign
- Spinal cord compression
Hip flexion
L2 to L4
Hip abduction
L4 to S1
Hip adduction
L2 to L4
Knee extension
L2 to L4
Knee flexion
L5 to S2
Dorsiflexion
L4 & L5
Plantar flexion
S1 & S2
Decreased strength
Nerve impingement
Passive straight leg test
SLR or Lasegue’s sign
Pain with dorsiflexion (SLR)
Sciatic issue over tight hamstring
Pain radiates down posterior/lateral side of leg
+ SLR
S1 or L5
Pain if leg is raised less than 30
Malingering
Pain on opposite side of raised leg
Significant nerve root compression due to central disc herniation
Positive crossed leg raise
- Asymptomatic leg is raised
Significant central herniation
- .9 specificity, not great sensitivity
Positive FABER
- Flexion, Abduction, & External rotation
Sacroiliitis
Pain worse with movement and sitting
Suggestive of mechanical pain
Pain radiating down leg & numbness
Suggest disc herniation
Pain improves in supine position
Suggest spinal stenosis or herniation
How soon should decompression done for cauda equina syndrome
72 hrs
Localizable bony tenderness
Dull, throbbing pain with slow progression
Worse with recumbency or cough
Malignancy
15 to 40 yr old
Morning stiffness and achiness over SI joint or lumbar spine
Ankylosing spondylitis
Aching back and posterior thigh discomfort
Increases with activity or bending
Spondylolisthesis
Studies for low back pain
CBC: Cancer of infection
X-ray: Specific guidelines
Lumbar Spine Film: Specific guidelines
MRI: Specific guidelines
X ray
Trauma Osteoporosis or Steroid use 70 Cancer or signs of cancer Pain worse when supine or severe at night
Lumbar spine
> 50 Trauma Neurological deficits Weight loss Hx of ankylosing spondylitis Drug or alcohol abuse Hx of malignancy Fever No improvement (no financial compensation)
MRI
Neurological deficits Radiculopathy Progressive motor weakness Cauda equina Systemic disorders Failed 6 weeks of conservative care
Bottom line of imaging
If no red flags are present do not image until 6 weeks
Therapy for back pain
NSAIDs
Local therapy (Hot/Cold)
Normal activity
PT (?)
Options if pain has no resolution follow appropriate conservative management
Refer to spine surgeon or pain clinic
- Progression or poor pain control
Continue conservative treatment (If no red flags)
- Ok to DC PT if patient has been getting and not had relief