SM 237: Back Pain

Question 1

What is the Socioeconomic impact of lower back pain?

Answer 1

3rd most common reason for primary care visit and most common cause of disability for patients under 45

Question 2

What are potential pain generators in the lower back?

Answer 2

Vertebral bodies, intervertebral discs, zygopophysial/facet joints, ligaments, nerves, muscles, sacroiliac joints

Question 3

Where in the lower back does most motion occur?

Answer 3

L4-L5 and L5-S1

Question 4

How does vertebral canal size change with flexion and extension?

Answer 4

Extension decreases and flexion increases in the lower back

Question 5

How does facet load change with extension and flexion?

Answer 5

Facet loads increase with extension and decrease with flexion in the lower back

Question 6

What lowers pressure on intervertebral discs?

Answer 6

Lying down on your side or back

Question 7

What raises pressure on intervertebral discs?

Answer 7

Bending forward, sitting, and sitting in bad posture - also the valsalva maneuver

Question 8

What causes discogenic lower back pain?

Answer 8

Pain caused by an intervertebral disc, due to irritation of nerve receptors innervating the annulus fibrosus and periosteum

Question 9

Why does pressure on a disc lead to tears?

Answer 9

The nucleus pulposis inside a disc is incompressible and leads to tears of the annulus fibrosus

Question 10

What is disc herniation?

Answer 10

Nucleus pulposus leaks out of the annulus pulposis and into the intervertebral disc space

Question 11

Where are disc herniations most common?

Answer 11

L4-L5, and L5-S1

Question 12

Can disc herniations happen acutely?

Answer 12

Yes, but they can also be chronic

Question 13

What is Lumbar radiculopathy?

Answer 13

Pain that radiates down a leg in a dermatomal distribution due to nerve root compression and inflammation, with sensory and/or muscle weakness in the same dermatomal weakness

Question 14

How does lumbar radiculopathy effect neurological findings?

Answer 14

Sensory symptoms, muscle weakness in a dermatome and abnormal reflexes

Question 15

What are zygopophysial joints?

Answer 15

Synovial joints where vertebrae interlock that can experience degenerative changes leading to joint pain

Question 16

What movement worsens lower back pain due to zygopophysial joints?

Answer 16

Zygapophysial joint-driven back pain worsens with extension, especially at the more mobile levels of the lower back L4/5 and L5/S1

Question 17

What imaging findings are consistent with Zygopophyial joint driven back pain?

Answer 17

None, imaging can vary if the Zygopophysial joint is causing lower back pain

Question 18

What is spinal stenosis?

Answer 18

A common source of pain and disability in the elderly population due to narrowing of the spinal canal

Question 19

How does prolonged walking effect vertebral size?

Answer 19

Prolonged walking causes extension, decreasing vertebral canal size

Question 20

What does “neurogenic claudication” refer to?

Answer 20

Leg pain with walking, prolonged standing, and downhill walking due to compression of the vertebral canal, releived by actions that induce flexion

Question 21

What is the “shopping cart sign”?

Answer 21

Found in spinal stenosis, relieves pain due to flexion increasing size of the vertebral canal

Question 22

How do muscles cause lower back pain?

Answer 22

Muscle itself may be strained or torn, or the muscle pain is secondary due to a disc injury or an irritated nerve

Question 23

What should a history for lower back pain cover?

Answer 23

Ask about a mechanism for a specific event, ask for alleviating or aggravating factors, ask about radiation/tingling/numbness/weakness and bower/bladder symptoms

Question 24

What are the specific alleviating or aggravating factors to ask about in lower back pain?

Answer 24

Positional stuff:

flexion vs extension
sitting vs standing
transitional pain
coughing, sneezing

Question 25

Why do we ask about bower/bladder symptoms in lower back pain?

Answer 25

Red flag symptoms indicating a CNS emergency

Question 26

What biopsychosocial factors can contribute to lower back pain?

Answer 26

Depression, anxiety, stress as well as attitude and fear-avoidance behaviors due to chronic back pain

Question 27

What should physical examinations cover in lower back pain?

Answer 27

Inspect in shorts, palpate bony and soft tissue structures, range of motion, neurological exam for radiculopathy, and neurodynamic testing

Question 28

What are neurodynamic tests?

Answer 28

Dural tensions signs that assess for nerve root issues possibly due to compression: straight leg raise, slump sit test, femoral nerve stretch

Question 29

What joint should be evaluated in lower back pain and why?

Answer 29

The Hip and spine joints, with focus on range of motion, because the back can refer pain to the hip and the hip can refer to the back/buttocks

Question 30

Is imaging necessary for lower back pain?

Answer 30

Not for the first 6 weeks, because radiographic findings do not correlate with clinical severity or outcome, and some patients have radiographic findings with no symptoms

Question 31

When should you order imaging in lower back pain?

Answer 31

If pain doesn't respond to treatment, suspected fracture, neurologic defects, vertebral infection or cancer

Question 32

What imaging test is used for lower back pain and what are you looking for?

Answer 32

Often use Xray, and look for fractures, alignment/spondylolisthesis/vertebral slipping, and disc height loss

Question 33

What does MRI look for in lower back pain?

Answer 33

Internal disruption of disc, Z-joing arthropathy, central or foraminal narrowing for nerve impingement, and fracture or infection

Question 34

What is the prognosis for lower back pain?

Answer 34

Most people improve in a week and up to 90% improve in the first 12 weeks; but pain may relapse and pain can become persistent

Question 35

What satisfies the patients most in lower back pain?

Answer 35

Patients who are given the best explanation of the problem causing their lower back pain

Question 36

How is lower back pain treated acutely?

Answer 36

Decrease pain/inflammation with PT and NSAIDS Early mobilization Directional movement pattern to centralize pain

Question 37

What are the active modalities to treat lower back pain?

Answer 37

Activity modification, lumbar stabilization, aquatic exercises

Question 38

Does lower back pain improve with bedrest?

Answer 38

Nope

Question 39

Why don't we give every patient the same exercise program to patients with lower back non?

Answer 39

Non-specific treatment for a non-specific problems leads to poor outcomes

Question 40

What characterizes subgroups of traetment?

Answer 40

Location, anatomic structure involved, and directional preferences

Question 41

What is directional preference?

Answer 41

A movement in a specific direction that removes pain from limbs and centralizes the pain to the back, allowing for pain-free motion, with very patient-specific treatments

Question 42

Is flexibility at the back or hip/knee most important to prevent lower back pain?

Answer 42

Flexibility at the hip/knee and stability in the back are better at preventing lower back pain

Question 43

How do core stabilizaiton exercises treat lower back pain?

Answer 43

They maintain spinal stability and help oppose the movements of limbs, works better than non-specific exercise

Question 44

Does walking benefit lower back pain?

Answer 44

Yes

Question 45

What spinal injections treat lower back pain?

Answer 45

Epidural injections for radicular pain, facet injections for facet mediated pain and medial branch blocks/ablation

Question 46

How are spinal injections performed, and with or without contrast?

Answer 46

Fluoroscopic guidance with contrast to avoid penetrating unwanted structures like vasculature

Question 47

When should someone be referred to surgery for lower back pain?

Answer 47

Cauda equina symptoms, progressive neurologic deficit, and suspected spinal cord compression; or if every non-surgical option has failed

Question 48

What is Cauda equina syndrome?

Answer 48

Saddle anesthesia, bladder dysfunction, and bilateral leak weakness due to compression of the Cauda equina

Question 49

What is Cauda equina syndrome?

Answer 49

Saddle anesthesia, bladder dysfunction, and bilateral leak weakness due to compression of the Cauda equina

Question 50

What is the difference between radiculopathy and radicular pain?

Answer 50

Radicular pain has no abnormal sensory or motor reflexes or muscle issues, just pain that radiates down the leg; radiculopathy implies pain + sensory and motor deficits