SM_237a: Back Pain Flashcards
Describe the socioeconomic impact/cost of low back pain
Socioeconomic impact/cost of low back pain
- 3rd most common reason for PCP visits in the US
- 1st most common cause of disability under age 45
- Affects up to 80-85% of adults at some point
- Estimated cost to US > $100B
- Most expensive healthcare problem for people ages 20-59
- Median time off work for back injury is 7 days
Describe the etiology of back pain
Back pain etiology
- Biomechanics
- Disc pressures
- Discogenic
- Disc herniation
- Lumbar radiculopathy
- Zygapophysial joint
- Spinal stenosis
- Muscle
Describe the pain generators of low back pain
Low back pain: pain generators
- Vertebral bodies
- Intervertebral disc
- Zygopophysial (facet) joints
- Ligaments
- Nerves
- Muscles
- Sacroiliac joints
Describe biomechanics of low back pain
Biomechanics of low back pain
- Greatest motion occurs at L4-5 and L5-S1
- Canal size decreases with extension and increases with flexion
- Facet load increases with extension and decreases with flexion
Greatest motion occurs at levels ____ and ____
Greatest motion occurs at levels L4-5 and L5-S1
Canal size _____ with extension and facet load _____ with extension
Canal size decreases with extension and facet load increases with extension
Canal size _____ with flexion and facet load _____ with flexion
Canal size increases with flexion and facet load decreases with flexion
____ is the position that puts the most amount of pressure on the disc
Sitting in poor posture is the position that puts the most amount of pressure on the disc
Discogenic back pain is caused by an ____ and involves ____
Discogenic back pain is caused by an intervertebral disc and involves irritation of nerve receptors innervating annulus fibrosis and periosteum
- Axia
- Worse with flexion and Valsalva maneuvers
Disc herniation occurs when ____ and is most common in levels ____ and ____
Disc herniation occurs when disc material extends outside of intervertebral disc space and is most common at levels L4-5 and L5-S1
- Most in common in ages > 55 years
- Can occur acutely and be associated with acute pain
Lumbar radiculopathy is caused by ____ and typically involves ____
Lumbar radiculopathy is caused by nerve compression / inflammation and typically involves lancinating pain radiating to leg in a dermatomal distribution (± back pain)
- Sensory symptoms and/or muscle weakness can be present
- Reflexes often abnormal
Zygapophysial is more prevalent in ____ patients and usually occurs at levels ____ and ____
Zygapophysial is more prevalent in older patients and usually occurs at levels L4-5 and L5-S1
- Generally worse with extension
- No consistent imaging findings in those with proven Z-joint pain
Spinal stenosis may involve ____ and is a common source of pain and disability in the ____
Spinal stenosis may involve neurogenic claudication and is a common source of pain and disability in the elderly
- Narrowing of the spinal canal
- Neurogenic claudication: leg pain with walking / prolonged standing / downhill walking and shopping cart sign (relieved with sitting, bending forward, or walking uphill)
____ would provoke symptoms in a patient with lumbar stenosis
Prolonged walking would provoke symptoms in a patient with lumbar stenosis
Muscle pain is often ____
Muscle pain is often secondary and referred
Describe history for back pain
Back pain history
- Only 20% recall a specific event
- Alleviating aggravating factors: flexion vs extension, sitting vs standing, transitional pain, coughing, sneezing
- Radiation, tingling, numbness, weakness
- Bowel / bladder symptoms
(also screen for depression and anxiety)
Describe physical exam for back pain
Back pain physical exam
- Inspection
- Palpatory exam
- Range of motion
- Neurologic exam: motor and sensory exam, reflexes
- Neurodynamic testing (dural tension signs): straight leg raise, slump sit test, femoral nerve stretch
It is important to assess ____ and ____ during physical exam for low back pain
It is important to assess areas nearby reported pain and the hips during physical exam
- Assess hips: check ROM, special test provocative maneuver, back can refer to hip, hip can refer to back and buttock
Imaging is ____ in the first 4-6 weeks and radiographic findings often ____ correlate with clinical severity or outcome
Imaging is not necessary in the first 4-6 weeks and radiographic findings often do not correlate with clinical severity or outcome
(radiographic findins in asymptomatic patients)
Describe when to consider ordering imaging for low back pain
When to consider ordering imaging for low back pain
- Pain not responding to treatment
- Suspected fracture
- Neurologic deficits: myelopathy, radiculopathy
- Suspected vertebral infection
- Suspected cancer
- Considering spine injection or surgery
X-ray is used to assess ____, ____, and ____ in low back pain
X-ray is used to assess fracture, alignment (spondylolisthesis), and disc height loss in low back pain
Describe uses of MRI for low back pain
MRI for low back pain
- Internal disruption of disc
- Z-joint arthropathy
- Stress reaction
- Fracture, infection, tumor
- Central or foraminal narrowing
- Nerve impingement
Acute treatment of low back pain involves ____, ____, and ____
Acute treatment of low back pain involves decreasing pain/inflammation, early mobilization, and directional movement pattern to centralize pain
(modalities and medications to decrease pain / inflammation)
Describe treatments for acute back pain
Acute back pain treatment
- Analgesic medications
- Epidural steroids
- TENS
- Cryotherapy
- Orthoses
- Manual therapy
- Acupuncture
Bedrest ___ low back pain
Bedrest does not improve low back pain
Exercise for low back pain ____
Exercise for low back pain is a non-specific treatment for a non-specific diagnosis, leading to non-specific results
(need to identify subgroups by location, anatomic structure / pain generator, and directional preference)
Physical therapy leads to ____ rates of patient satisfaction / return to work and ____ rates of patients going to surgery
Physical therapy leads to high rates of patient satisfaction / return to work and low rates of patients going to surgery
Describe flexibility, core stabilization, and aerobic fitness in treatment of low back pain
Low back pain
- Flexibility not important - more important is flexibility at hips and knees with stability at spine level
- Core stabilization is important in maintaining spinal stability and is more effective than general exercise for decreasing pain and improving function in the short term
- Walking decreases spinal loading and improves pain and functional scores
Describe spinal injections for treatment of back pain
Spinal injections for treatment of back pain
- Types: epidural injections, facet injections, medial branch blocks / ablation
- Symptoms refractory to initial conservative interventions
- Can be useful in combination with other treatments
- Fluoroscopic guidance and live contrast injection to avoid intravascular injection
- Epidural steroid injections: transforaminal / interlaminar / caudal, radicular pain or suspected nerve root irritation, may be surgery sparing
- Facet injections: chronic facet-mediated pain
Surgical referral for back pain is required if patient ____, ____, ____, and ____
Surgical referral for back pain is required if patient has cauda equina symptoms, progressive neurologic deficit, suspected spinal cord compression, or failed comprehensive trial of non-surgical treatment
Low back pain often ____ but often ____
Low back pain often resolves but often recurs
