Lower Back Pain

Question 1

Mechanical v. Non-Mechanical Presentation/Causes

Answer 1

MECHANICAL
- Inc w/ activity and relieved w/ rest (accounts for 95% low back pain); NOT inflammatory or due to neoplasm

• Causes - spondylosis, disk herniation, spinal stenosis, fracture/osteoporosis

NON-MECHANICAL

• Inflammatory- Spondyloarthritis
• Infectious - vertebral osteomyelitis, epidural abscess, septic diskitis, herpes zoster
• Metabolic - osteoporosis
• Referred visceral pain - retroperitoneal including aorta

Question 2

Spondyloarthritis

Answer 2

(esp in men < 40 yo)

• Similar to RA; morning stiffness, better w/ activity

Question 3

Eval of Lower Back Pain

Answer 3

• Goal is to ID 5% w/ non-mechanical
• Look for - trauma, steroid use, nocturnal pain, cancer, wt loss, bowel or bladder symptoms, severe morning stiffness in lower back
• PE - motion and point tenderness; neuro exam
• Imaging - XRay, MRI (r/o some above if persistent 6-8 wks)
• EMG or nerve conduction studies (not done in all - if persistent and suspect nerve compression)
• Labs - CBC, CRP, ESR

Question 4

Acute v Chronic Tx

Answer 4

• For acute (<3 mo) - good prognosis
  
  • Acetaminophen and NSAIDs
  • Short-term opioids if severe or cannot use NSAIDs
  • After acute symptoms resolve - do PT
• For chronic (>3 mo)
  
  • Use acetaminophen and NSAIDs in flares
  • Avoid long-term opioids and surgeries - poor outcomes
  • Use PT, vocational, education

Question 5

5 Indications for Spinal Surgery

Answer 5

1- Cauda Equina Syndrome

2- Progressive neuro deficits > 6 wks

3- Disk herniation w/ severe neuro deficits

4- > 6 wks disabling radiculopathy

5- Spinal stenosis w/ severe neuro deficits or disabling symptoms

Question 6

Lumbar Spondylosis

Answer 6

• OA of spine in diskoverterbal joints and facet joints

- Most common

Question 7

Disc Herniation

Answer 7

• when nucleus pulposus in degenerative nerve pushes out of weak annulus –> possible nerve root impingement (impinges on SC)
• 95% in L4-L5 (absent knee jerk?) and L5-S1 (absent ankle jerk)
• Common cause sciatica (dermatome of pain usually to foot/ankle)
  - Shooting/sharp pain, numbness/tingling, inc w/ cough, sneeze or Valsalva
  - Can cause Cauda Equine Syndrome - bowel or bladder dysfunction
  - PE - lifting leg while laying puts tension on sciatic nerve

Question 8

Lumbar Spinal Stenosis

Answer 8

• narrow central canal compressing nerve roots
• Indication for spinal surgery
• Feels better when leaning forward b/c open up space for SC