Physical Exam-Low back Flashcards
What questions do you ask in diagnosing inflammatory back pain?
Morning stiffness > 30 minutes, Improves with exercise, does not improve with rest, pain in second half of night and buttock pain.
What are the red flags for back pain?
Major trauma, age > 50, fever, infection, cancer, metabolic disorder, major muscle weakness, incontinence, saddle anesthesia, unrelenting night pain, IV drug use and progressive neurological defect.
What are you looking for when you do a straight-leg raise test on a patient?
Radiating leg pain below the knee.
Sclerotomal pain
Facet disease, disc disease or a muscle/ligament
Radicular pain
Pain due to a nerve root.
What is included in sciatica?
Sclerotomal and radicular pain
A 35 year old complains of low back pain for 8 weeks. He has no red flags, pain when patient leans to the right and a positive straight leg raise test on the left. You decide to order an X-ray and find spondylosis of the L5 vertebra. What do you initially prescribe?
Spondylosis just means degenerative disease. Minimal bed rest, manipulation, aerobic exercise, NSAIDs and muscle relaxants.
In a patient without a red flag, when do you decide to get imaging of their back?
90% of patients without sciatica will get better on their own in 4-6 weeks and don’t need imaging. If their pain does not resolve by then get imaging done.
What is the downside of running someone with back pain through an MRI or CT scan?
It is highly sensitive but not specific.
How can you narrow your diagnosis for someone with neurological defect?
Nerve conduction and EMG
A patient shows no improvement after 3 weeks of conservative measures and shows diminished reflex of the a chiles tendon and patellar reflex. What nerves are indicated by these reflexes?
Achilles: S1 Patellar: L4
How would you differentiate in your physical exam between spondylolysis and disc herniation?
Disc herniation is exacerbated by flexion of the spine, spondylolysis is exacerbated by extension of the spine.
A 78 year old male has a 1 year history of LE weakness with prolonged walking. Pain is worse walking down stairs. He reports relieve when leaning over a shopping cart. What is your diagnosis?
Neurogenic claudication indicates spinal stenosis.
A 35 year old male has a history of low back pain and stiffness. He gets better with exercise and pain bounces back and forth between right and left buttock. He has also recently been diagnosed with an infection. What is your diagnosis?
This is an inflammatory arthritic condition called spondyloarthritis. It has many forms including psoriatic arthritis and ankylosing spondylosis.
How do you treat someone with inflammatory low back pain?
NSAIDs
