Lumbar Spine

Question 1

How long should you wait to get an MRI for back pain?

Answer 1

6 weeks b/c most resolves on its own

Question 2

What is the most common cause of lumbar back pain?

Answer 2

Acute lumbar strain

Question 3

Acute lumbar pain
Type of pain
Cause
Diagnosis
Treatment

Answer 3

• Sudden, non-radicular pain
• Caused by injury to muscle, tendon, or ligaments, usually from a lifting or twisting injury.
• Diagnosis - H&P
• Treatment – ice / heat, 1-2 days bed-rest (longer is bad), NSAIDs, narcotics / muscle relaxants (avoid if possible), time, PT (trunk stabilization, core strengthening) only after pain has stopped.

Question 4

Chronic low back pain
Cause
Treatment
What should NOT be done?

Answer 4

• Usually due to degenerative changes in disk and facet joints. Analogous to OA. Related to obesity, poor core strength, poor posture, and repetitive loading activities.
• Treatments are active – aerobic exercise, PT, weight loss, px education.
• Passive treatments do NOT work – meds, massage, heat, injections, or braces
• Do NOT use surgery or narcotics.

Question 5

Most common age for acute disc herniations

Answer 5

20-45 y/o

Question 6

Myotome for hip flexion

Answer 6

L2,3

Question 7

Myotome for hip extension

Answer 7

L4,5

Question 8

Myotome for knee extension

Answer 8

L3,4

Question 9

Myotome for knee flexion

Answer 9

L5,S1

Question 10

Myotome for dorsiflexion

Answer 10

L4,5

Question 11

Myotome for plantarflexion

Answer 11

S1,2

Question 12

Myotome for foot inversion

Answer 12

L4

Question 13

Myotome for foot eversion

Answer 13

L5,S1

Question 14

Treating acute disc herniation

Answer 14

• 80% resolve spontaneously in 6-10 weeks. Begin PT at time of diagnosis.
• Walk for exercise (aerobic).
• Meds: NSAIDs, gabapentin, medrol
• Epidural steroid injections don’t stop herniation but reduces inflammation / pain
• Bed rest is NOT recommended.
• Consider surgical discectomy at 2-3 months if no pain relief. Surgery makes recovery faster, but long-term there isn’t much difference.

Question 15

Absolute / relative indications for surgery after acute disc herniation

Answer 15

• Absolute: cauda equina syndrome or advancing progressive neurologic deficit
• Relative: intractable pain for >2 months, nerve root deficit (weakness / numbness), functional limitations, inability to sleep

Question 16

Spinal stenosis
3 causes
Epidemiology: age, gender
Sxs
Treatment

Answer 16

• Caused by degenerative facet joint hypertrophy (may lead to subluxation / spondylolisthesis), disk degeneration, or ligamentum flavum hypertrophy.
• Pxs are usually age 40-80, women, and obese
• Sxs – Usually progress gradually. Pain w/ standing / walking (back, butt, thigh), neurogenic claudication, worse w/ extension.
• Sxs usually do not correlate w/ severity of MRI
• Gets better w/ sitting or forward flexion
• Treatment – PT, anti-inflammatory meds, epidural steroids, activity modification, weight loss, surgical decompression

Question 17

Spondylolisthesis
Where do most cases of spondylolisthesis occur?
Age
Sxs
Diagnosis
Treatment

Answer 17

• L5 (90%)
• Most occur during childhood (age 8-15). More common in athletes.
• Most spondylolysis cases are asymptomatic. Pain may be worse w/ extension and better w/ flexion.
• Diagnosis – history, LBP w/ L5 radiculopathy. Pain is worse w/ extension and better w/ flexion. PE shows palpable “step off” in lumbar spine. X ray is diagnostic.
• Treatment
• Initial – rest, NSAIDs, core strengthening, bracing, nerve root block
• Surgery for cases w/ persistent pain or worsening slip. Involves fusion b/w L5-S1

Question 18

3 causes of sciatica

Answer 18

Disc herniation, spinal stenosis, and spondylolisthesis