Lower Back Pain Lecture Powerpoint Flashcards
Lower back pain is the ___ most common reason to visit healthcare providers, up to __% of people experience it during their lifetime. The same percent of those seen in primary care will have ____ type lower back pain
- 2nd
- 80%
- nonspecific
Nonspecific back pain definition
Back pain in the absence of an underlying cause that is mostly musculoskeletal pain (mechanical cause) and does not warrant diagnostic testing and improves in a few weeks
The C and L spine should have a ___ curvature while the T should have ___
Lordosis, kyphosis
When documenting, don’t need to cite specific muscle but describe location using anatomic clues example
Ex) paraspinal tenderness (important to differentiate between on the spinous process and on the muscle
As we age, ligaments of the back can lose elasticity becoming…
…hypertrophic which can result in compression of the spinal cord on the thecal sac or a slip of the disks
Sciatic nerve is formed from…
…L4 to S3
Herniated disks can heal on their own because…
….the nucleus pulposis will dry and shrink over time after being herniated
Classification of back pain based on duration
Acute - <4 weeks
Subacute - 4-12 weeks
Chronic - >12 weeks
Recurring - intermittent episodes with pain free periods
3 broad categories of back pain
1) nonspecific low back pain
2) serious systemic etiologies (spinal cord compression/cauda equina, metastatic cancer, epidural abscess, vertebral osteomyellitis)
3) less serious specific etiologies (vertebral compression fracture, radiculopathy, spinal stenosis)
Some other common etiologies of back pain (5)
- ankylosing spondylitis
- osteoarthritis
- scoliosis
- psychological
- pancreatitis/nephrolithiasis/pyelonephritis/herpes zoster
Mechanical risk factors for back pain (5)
- heavy physical work
- heavy lifting
- twisting and vibration
- posture
- obesity
Serious systemic etiologies for back pain (3)
- spinal cord compression/cauda equina syndrome
- metastatic cancer
- spinal epidural abscess or other infection
Suspected musculoskeletal back pain lasting over ___ should raise concern and confirm need to complete diagnostic studies
4 weeks
Cauda equina syndrome and symptoms (1 big one and 3 others)
Compromised canal of the spinal cord beneath L1 that needs emergent referral to neurosurgery to prevent permanent loss of function
- Urinary retention***
- perianal anesthesia
- decreased anal sphincter (late finding)
- herniated nucleus pulposis
Radiculopathy
Dysfunction of the nerve root causing pain, sensory impairment, weakness, decreased DTR in a nerve root distribution including things such as sciatica
Vertebral compression fracture and 3 risk factors and a key treatment
- Collapse of the vertebral body most often nonemergent concern that self limits
- older age, osteoporosis, steroid use
- kyphoplasty
Piriformis syndrome
Thickened piriformis muscle that puts pressure on sciatic nerve seen often in those that sit a lot on a bike or even some runners that can be a source of sciatica
Spinal stenosis
Narrowing of spinal canal that results in bony constriction of the cauda equina in patients greater than 65 from neurogenic claudication resulting in pain walking or standing that decreases when sitting or in spinal flexion
Ankylosing spondylitis
Inflammatory arthritis of spine causing chronic back pain most common in men under 40 characterized by morning stiffness that is improved with exercise and worsened (often awakening) in the night
Waddells sign
Psychologic distress contributing to back pain symptoms and display associated and inappropriate physical signs (overreaction during physical exam, superficial tenderness, improvement upon distraction, nondermatomal distribution of sensory loss)
Differential diagnosis of back pain without radiculopathy (6)
- musculoskeletal pain
- retroperitoneal neoplasm
- ankylosing spondylitis
- depression
- epidural abscess
- malingering
Differential diagnosis of back pain with radiculopathy (4)
- herniated nucleus pulposis
- spinal stenosis
- compression fracture
- malingering
Constitutional red flags of lower back pain (5)
- unintentional weight loss
- fever/night sweats
- night pain
- history of malignancy
- IV drug use
Bowel/bladder red flags of lower back pain (2)
-retention
-incontinence
(these are LATE findings!)
Patrick’s FABER test and what 2 things does it test?
A test of flexion, abduction, and external rotation of the hips and SI joints
Straight leg raising
A test of keeping the knee straight while lifting leg up, if decreased on one side indicative of nerve root irritation in sciatica
Physical exam red flag findings for lower back pain (7)
- saddle anesthesia
- loss of anal sphincter tone (late finding)
- major motor weakness
- elevated temp
- vertebral tenderness
- extremely limited range of motion
- pain not reproducible by exam
Musculogiamentous strain and treatment options (5)
- Usually brought on by a precipitating event that causes sensation of giving way of back associated with severe pain, radiation is rare
- Rest and moderate activity, ice, NSAIDs, muscle relaxants (make drowsy and can’t drive), PT
Contraindications to NSAIDs for lower back pain (4)
- peptic ulcer disease
- bleeding
- anticoags
- renal dysfunction
NSAID medication options for lower back pain (5)
- ibuprofen
- naprosyn
- relafen
- meloxicam
- celebrex
Opioids and systemic steroids provide no better benefit than ___
NSAIDs
Lumbar disc herniation classic presentation
Radiculopathy, burning pain along distribution of affected nerve root
Lumbar disc herniation treatments (3)
- 80% self resolve
- NSAIDS
- epidural steroid injections
Spinal stenosis is worsened with what motion?
Increased spinal extension
Pharmacologic treatment options for spinal stenosis (3)
- NSAIDs
- Acetaminophen if cannot tolerate them
- tramadol
Spondylosis vs spondylolysis vs spondylolisthesis
- Spondylosis is osteoarthritis of the spine causing wear and tear
- Spondylolysis is a defeect or stress fracture in the pars interarticularis (young athlete) giving scotty dog appearance on oblique film
- spondylolisthesis is a defect or fracture of bilateral pars resulting in slippage graded 1-5 needed to be stabilized with rods
Imaging for lower back pain
- not indicated for mechanical or acute pain less than 4 weeks
- if red flag (under 18 over 50) or fever
- plain x ray first
- MRI test of choice
- CT for fractures
