Module 9.2 - Back pain Flashcards
What is back pain?
Pain in the lumbosacral region of the spinal column which causes discomfort and limited range of motion. Low back pain may be associated with varying degrees of neurologic symptoms and radiation to the lower extremities with an inability to perform ADLs.
Describe the etiology of back pain
- Most common reason for patients under 45 years of age in the US to seek medical care.
- Affects up to 84% of adults at some point in their lives.
- Most episodes are usually self-limited and resolve in < 3-4 weeks
- Costs the US economy $300 billion per year in lost workdays
What are the 5 types of back pain syndromes?
1. Back strain – characterized by paraspinal muscle spasms, listing to one side, decreased ROM, positive straight leg test
2. Discogenic Low Back Pain (DLBP) –
- Annular fibrosus when it is stretched with a bulging disc
- Outer 1/3 of disc has sensory innervations
- Radial fissuring is associated with painful discs
3. Spondylolysis and Spondylolithesis –
- Spondylolysis- stress fracture in pars interacticularis
- Spondylolisthesis- stress fracture and sliding of vertebra
4. Spinal Stenosis –
- Associated with neurogenic claudication (back, buttock and leg pain during ambulation, improves at rest)
- Narrowing of the spinal foramen leading to encroachment on spinal nerve roots
5. Disc Herniation – a condition in which the annulus fibrosus (outer portion) of the vertebral disc is torn, enabling the nucleus (inner portion) to herniate or extrude through the fibers
What are common causes of lumbar spine pain?
- Mechanical strain
- Obesity
- Poor body mechanics
- Trauma
- Repetitive twisting, bending or lifting
- Herniated lumbar disks- can precipitate sciatica (shooting pain starting at mid-buttocks and radiating down leg)
- Spondylolysis – neural arch defect in vertebral body
- Spondylolisthesis – forward subluxation of vertebral body due to defect in neural arch of vertebral body; varying grades of subluxation depending upon severity of vertebral slippage
- Spinal stenosis – narrowing of the spinal canal, or foramen, in which spinal nerves exit the spinal cord
- Degenerative disk disease
- Osteoarthritis
- Metastatic or primary tumors
- Rheumatologic diseases, i.e. ankylosing spondylitis
What are the subjective/physical exam findings associated with lower back pain?
A. Pain in the lower back region of the spine; may involving radiculopathy (radiating pain) in affected dermatome.
B. Numbness along the affected dermatome.
C. Bowel, bladder or sexual dysfunction
What is cauda equina syndrome?
- It is a gradual to sudden weakness and or inability to life or move legs; bowel and/or bladder incontinence or retention; and loss of or diminished sensation in legs.
- ** Cauda equina syndrome is a surgical emergency and requires an emergency MRI and consultative referral!
What are some findings associated with cauda equina?
Motor dysfunction: lower extremities, multiple muscle groups
Sensory dysfunction: saddle anesthesia; either incontinent or retaining of urine/stool
Reflex: sphincter tone diminished or absent
What are some red flags when assessing a patient with lower back pain?
- Pain associated with neurological deficits (weakness, altered sensation, bowel/bladder changes)
- Pain associated with fever and/or stiff neck
- Pain associated with unexplained weight loss with or without a previous history of malignancy
- Pain worse at rest
- Pain associated with radiation to the abdomen or stomach area
- Pain related to the history of urinary tract infections, drug use or other infections (including AIDS)
- Pain increases with coughing/sneezing and/or straining
What are some physical exam findings seen with lower back pain?
A. Inspection of back and posture: can reveal scoliosis or hyper kyphosis
B. Palpation/percussion of the spine: assess vertebral or soft tissue tenderness; tenderness/pain present in patients with vertebral compression fractures, vertebral metastasis, infection
C. Neurologic exam: evaluate reflexes, strength, sensation and gait
D. Straight leg raising: useful in identifying whether symptoms are radicular in nature
E. Nonorganic sigsns (Waddel’s signs)
What are some nonorganic lower back pain signs (Waddell’s signs)?
- Overreaction during physical examination
- Superficial or widespread tenderness
- Inconsistent supine and seated (distracted) straight leg raise test
- Unexplainable neurologic deficits
- Pain on simulated axial load (top of head pressure)
These findings suggest psychological component, depression, anxiety
What diagnostic tests are used to diagnose lower back pain?
The majority of patients with back pain of < 4-6 weeks duration do not require imaging. Joint guidelines from the American College of Physicians and American Pain Society recommend that routine imaging for nonspecific low back pain should be avoided and reserved for patients with severe or progressive neurologic deficits or when serious underlying conditions are suspected.
- Plain x-rays (anteroposterior (AP) or lateral) are useful to rule out bony deficits, scoliosis, bone spurs.
- MRI without contrast is considered the best initial exam and is useful for detailed bony imaging, soft tissue structures and delineating disc bulges
- CT scan is useful for detailed bony imaging.
- Myelography of spine with or without CT scan- shows filling defects along spinal nerve roots- not often utilized anymore unless MRI is contraindicated.
How do you manage a patient with lower back pain without surgery?
- Rest- NOT bedrest
- Alternate ice/heat
- NSAIDs for mile to moderate pain
- Antispasmodic for severe muscle spasms
- Opioids for short-term acute back strain to promote mobility- **Consider adverse side effects, screen for abuse potential prior to prescribing, check state database for controlled substance prescription history; limit use to patients in severe pain that is either acute ,or has failed all other therapies.
- Anticonvulsants, such as gabapentin, pregabalin or antidepressants, such as venlafaxine, duloxetine, for pain that is neuropathic in origin.
- Physical therapy for toning and strengthening muscles
- Weight loss program
- Epidural steroid injections- patient referred to pain management for treatment
- Acupuncture- some use in older adults who are not surgical candidates
Describe the surgical management of a patient with lower back pain
- Foraminotomy and discectomy for nerve root decompression in spinal stenosis
- Depending on number and level of disks, may require spinal fusion with bone grafts
What is a herniated disk?
A bulging or protrusion of the nucleus pulposus through a defect in the annulus of the cervical, thoracic and lumbosacral intervertebral disks. The herniated disk may encroach on the peripheral nerves exiting the spinal cord.
What causes a herniated disk?
- Degeneration of the nucleus pulposis (the portion of a disk that contains gelatinous material enclosed in a fibrous band)
- Dehydration of the disk
- Trauma
- Valsalva maneuver- forceful coughing/sneezing
- Sedentary lifestyle
- Obesity
- Peak incidence between 34-45 years of age
- 90% of herniated disks located at L4-L5 and L5-S1
What are the physical exam findings associated with a herniated disk?
- Dependent upon spinal nerve root affected
- Decreased or absent reflexes innervate by specific nerve
- Atrophy of muscles innervated by affected nerve in chronic compression
- Antalgic gait: limp
- Proprioception (position sense) decreased
- Possible positive straight leg tests- indicative of radicular or sciatic pain
- Limited ROM of spine
- Positive pelvic rock test: test for sacroiliac (SI) joint dysfunction
What findings are associated with an L4 nerve root herniation?
Occurs with pathology in the disk between L3 and L4
Motor dysfunction: quadriceps muscles weak/atrophic
Sensory dysfunction: pain radiating into medial malleolus, numbness along same path, including medial aspect of knee
Reflex: diminished or absent knee jerk
Screening examination: have patient squat and rise.
What findings are associated with an L5 nerve root herniation?
Pathology occurs in the disk between L4 and L5
Motor dysfunction: weakness of dorsiflexion mechanisms of great toe and foot
Sensory dysfunction: pain radiating into lateral calf, numbness of dorsum of foot and lateral calf and between first toe web space.
Reflex: none at this level
Screening examination: have patient walk on heels of feet
What findings are associated with an S1 nerve root herniation?
Pathology occurs in the disk between L5 and S1
Motor dysfunction: weakness of plantar flexion of great toe and foot
Sensory dysfunction: pain along buttocks, lateral leg and lateral malleolus; numbness on lateral aspect of foot and in posterior calf (gastrocnemius muscle)
Reflex: diminished or absent Achilles reflex
Screening examination: have patient walk on their toes
