Spinal Disorders/Back Pain Flashcards
What is the 3rd leading reason for medical visits?
Back pain.
What is the MC cause for worker disability under the age of 45?
Back pain.
**Lifetime prevalence of 85%
What is very important to ask about a pt’s HPI of back pain?
Does the pain radiate??
What are some aggravating factors of associated with back pain?
- Sitting (related to disc herniation, pinching of nerve).
- Weight bearing (more hip pathology).
- Walking
What is important to remember about the timing of a pt’s back pain?
-Nighttime Pain?? *worrisome for malignancy.
- Early morning pain? RA, other autoimmune, OA.
- -How long does that morning pain last? RA longer (>1hr) needs a warming up period vs OA (10-15 mins).
Severity of back pain?
- Pain scale of 0-10.
- What’s worse….back pain or the radiating leg pain?
- Function…what CAN’t you do?
Why is it important to have your pt describe their back pain?
- Benign back pain is often “aching” or “burning.”
- Pathological back pain or non-spinal causes:
- PANCREATITIS = “Burning or piercing” mid-back pain w/elevated amylase, lipase.
- AORTIC DISSECTION = “Tearing” chest and mid-back pain; a surgical emergency.”
- NEPHROLITHIASIS = Lumbar pain radiates to groin, “Colicky.” Hematuria, Renal CT.
- PYELONEPHRITIS = Flank pain, provoked by percussion at CVA. Dysuria, Pyuria.
- AUTOIMMUNE, INFLAMMATORY = Back and multiple involvement. Elevated ESR, ANA.
- FIBROMYALGIA = painful trigger points throughout the body.
Other factors to consider with a complaint of back pain?
- Paresthesias = numbness, tingling, pins/needles, etc.
- Weakness = full body or specific area.
- Urinary incontinence = sacral nerve.
- Saddle anesthesia = sacral nerve.
Making the diagnosis based on history…
- Sciatica = disc herniation, spondylolisthesis.
- Trauma w/local back pain = compression fracture.
- Leg pain worse standing/walking = spinal stenosis, neurogenic claudication.
- IV Drug user = spinal abscess, discitis, osteomyelitis.
- Work injury, Insurance settlement = Malingering (diagnosis of exclusion).
Innervation of Hip flexion?
L1, L2.
Innervation of knee extension?
L3, L4.
Innervation of Dorsiflexion?
L4.
5 important things to check on the strength examination of a pt with complaints of back pain?
- Hip flexion (L2, L3).
- Knee extension (L3, L4).
- Dorsiflexion (L4).
- Extensor Hallucis Longus (L5).
- Plantar-flexion (S1).
Innervation of Extensor Hallucis Longus?
L5.
Innervation of Plantar-flexion?
S1.
PE topics to focus on when a pt complains of lower back pain?
- Inspection.
- Palpation.
- Strength and grading.
- ROM.
- Gait.
- Sensation.
- DTRs.
- Special Techniques.
Identify the Special Tests:
- Straight leg raising test.
- Crossed or Contralateral Straight Leg Raising Test.
- Internal/External Hip Rotation.
- To determine if a patient w/low back pain has an associated nerve root irritation or entrapment; such as the sciatic nerve.
- Straight leg raising test of the unaffected side; if Sx reproduced…highly associated with herniated disc and sciatic radiculopathy (about 97% of the time).
- Will identify if the pain is coming from the hip.
Back pain that affects muscles/tendons/ligaments and associated with a single or multiple traumatic events?
Lumbar Strain.
Prevalence and causes of Lumbar strain?
- Very common; 70% of back pain diagnoses.
2. Trauma, OBESITY, poor muscle tone, poor lifting technique, high heels, deconditioning.
Presentation of Lumbar Strain?
- Back pain.
2. NO radicular symptoms.
What are radicular symptoms?
Radiating pain that follows a dermatome.
**Memorize your dermatomes.
LOSS OF DISC HEIGHT with bone spur formation and thickened ligaments caused by aging and repetitive trauma?
Degenerative Disc Disease (DDD).
Prevalence of DDD?
- Very common.
- Age 45+.
- Female > Male.
- Obesity.
**Also the same for Facet Syndrome.
Presentation of DDD?
Back pain with stiffness, sore back, no radiation.
Complaint of “back went out.”
Continuation or 2/2 to DDD of spine?
Facet Syndrome.
Patho of Facet Syndrome?
- *Loss of disc space height (DDD):
- -Increased load on facet joints.
- -Increased wear on articular cartilage.
Presentation of Facet Syndrome?
- Chronic LBP not responsive to traditional mgmt.
2. May have increased pain w/side bending.
Protrusion or Extrusion of a intervertebral disc? What can happen with this condition?
Herniated Disc can cause compression of a spinal nerve.
Most common location (not vertebral level) of a herniated disc?
Paracentral location is MC; lateral disc herniation can happen.
Presentation of herniated disc?
- Pain, paresthesias, weakness.
- In the distribution of a spinal nerve (dermatome).
- Worse sitting, better standing.
Narrowing of the spinal canal?
Spinal stenosis.
**Compresses the spinal nerves.
Emergency complication of Spinal Stenosis?
Compressing of the Cauda Equina (Cauda Equina Syndrome).
Presentation of Spinal Stenosis?
- Pain, paresthesias of legs with lack of stamina in legs.
- WORSE STANDING OR WALKING, BETTER SITTING.
- Neurogenic Claudication.
Where does the spinal cord end?
at the level of L1 or L2.
What vertebral levels is the cauda equina located?
L1-L5.
What is another name for neurogenic claudication and what is it?
Pseudoclaudication; compression of the nerves in the lumber region causing leg pain, more specifically, difficulty or weakness with walking.
Why is pain worse with standing or walking and better with sitting in Spinal Stenosis?
When you sit, the SC opens up. When you sit, the SC narrows.
Compression of the cauda equina?
Cauda Equina Syndrome.
**A surgical emergency!!!
What causes Cauda Equina Syndrome?
- Spinal Malignancy.
- Vertebral Fracture.
- Disc Herniation.
- Spinal Stenosis.
**Anything that can compress the cauda equina.
Presentation of Cauda Equina Syndrome?
- Low back pain that is very severe.
- Saddle anesthesia.
- Urinary incontinence.
- Impotence.
Why do the symptoms of Cauda Equina manifest?
The cauda equina houses the sacral plexus (S1-S4) which innervate the pelvic muscles, perineum and organs in the pelvis.
A “slip” of one vertebra with respect to another?
Spondylolisthesis.
What is the cause of Spondylolisthesis…aka the “slip” and what may it cause?
A fracture of the pars interarticularis.
It may cause Spinal Stenosis or pinch a spinal nerve.
What is the pars interarticularis?
Also ‘pars’ for short, is the part of a vertebra located between the inferior and superior articular processes of the facet joint.
It is an area most stressed by translational movement between the adjacent segment.
Presentation of Spondylolisthesis?
- Local low back pain.
- Better lying.
- With or without radiculopathy or neurogenic claudication.
**More of a bony back pain.
An abnormal curvature of the spine in the coronal plane?
Scoliosis.
What may also be associated with Scoliosis?
Abnormal sagittal kyphosis – Kyphoscoliosis.
*Abnormal curvature of the spine in two planes; the coronal plane (side to side) and the sagittal plane (back to front).
Presentation of Scoliosis?
- Back pain.
- Rotation of rib cage.
- Uneven hips.
What is the Cobb Angle?
The measurement of the degree of side-to-side spinal curvature.
What is an infection of the intervertebral disc?
Discitis.
What may extend to the body of the vertebra from Discitis?
Vertebral Osteomyelitis – infection of the bone.
Who is Discitis and Osteomyelitis common in?
Diabetics and IV Drug users.
Presentation of Discitis and Vertebral Osteomyelitis.
- Severe back pain.
- Malaise.
- Ill-appearing.
- May have a fever.
The collapse of the body of a vertebra, thoracic and upper lumbar?
Vertebral fracture.
What are the causes of a Vertebral Fracture?
- Traumatic - severe MOI.
2. Pathological – Osteoporosis, malignancy.
Presentation of Vertebral Fracture?
- History of trauma – is it severe enough to cause this Fx?
- Back pain.
- May have Sx of compression of a spinal nerve, spinal cord, or cauda equina.
The vast majority of low back complaints arise from what vertebral level?
L4-S1 (L4/5, L5/S1).
Disc L1-2…nerve, pain, radiation, reflex, muscle?
L1-L2:
- Nerve = L2.
- Pain = lower back pain.
- Radiation = groin, medial thigh.
- Reflex = none.
- Muscle = none.
Disc L2-3…nerve, pain, radiation, reflex, muscle?
- Nerve = L3.
- Pain = lower back pain.
- Radiation = antero-medial thigh.
- Reflex = none.
- Muscle = hip flexors (iliopsoas).
Disc L3-4…nerve, pain, radiation, reflex, muscle?
- Nerve = L4
- Pain = lower back pain.
- Radiation = anterior thigh patella.
- Reflex = KNEE.
- Muscle = knee ext…Quadriceps.
Disc L4-5…nerve, pain, radiation, reflex, muscle?
- Nerve = L5.
- Pain = lower back pain.
- Radiation = lateral thigh, lateral calf, dorsum of foot
- Reflex = none.
- Muscle = Great toe…Extensor Hallucis Longus (EHL).
Disc L5-S1…nerve, pain, radiation, reflex, muscle?
- Nerve = S1
- Pain = lower back pain.
- Radiation = Lat. thigh, lat. calf, lat. foot.
- Reflex = ANKLE.
- Muscle = Plantar flexors…Gastrocnemius.
Spinal imaging diagnostic for Back Pain?
- XR.
- CT Scan (non-contrast).
- MRI.
- Myelogram w/post-myelogram CT Scan.
Indications and views for L-Spine XR?
Indications:
-Trauma, back pain w/Hx of malignancy, back pain over a month.
Views:
-AP, Lateral, Oblique, Flexion/Extension.
Why is a Flexion/Extension view necessary on L-Spine XR?
To assess for the stability of a ‘Slip’ of a vertebra.
Indications and views for Non-Contrast CT Scan?
Indications:
-Trauma, Vertebral Fx, Eval of Lytic Lesions.
Views:
-Axial, Sagittal, Coronal.
What is the ‘Go-To’ imaging for Radicular pain?
MRI.
Indications, views and contraindications of MRI?
Indications:
-Radicular pain, Neurogenic claudication, Cauda Equina Syndrome (Stat MRI), New back pain w/Hx of malignancy.
Views:
-Axial, Sagittal, Coronal.
Contraindications:
-Pacemaker, neurostimulators.
Who is a Myelogram indicated for?
Those that have a contraindication for MRI.
Indications and views of Myelogram w/Post-Myelogram CT?
Indications:
-Neural compression, vertebral Fx, OK for pacemakers and neurostimulators.
Views:
-Myelogram, CT Post Myelogram.
How is the iodinated contrast injected?
Intrathecal.
Treatment of Back Pain?
- Injury Prevention.
- Home Interventions.
- Physical Therapy (PT) - massage, TENS unit, active exercises.
- Chiropractic - Spinal manipulation.
- Acupuncture.
- Medications.
- Referrals.
Examples of Injury Prevention and Home interventions for treating back pain?
Injury Prevention:
-Core strength, proper lifting techniques, ergonomic work stations.
Home Interventions:
- Rest 1-2 days.
- ICE in acute phase, then heat.
- Gradual return to normal activities.
- Avoid prolonged work/school excuse.
- Support brace (little role).
Examples of medications for treatment of back pain?
- NSAIDs or Acetaminophen.
- Narcotics (acute phase only).
- Muscle relaxants (acute phase only).
- Antidepressants (improve pain threshold).
- Anticonvulsants (improve painful paresthesias).
Examples of referrals for treatment of back pain?
- ER for surgical consultation…Cauda Equina Syndrome.
- PT…back pain >1 month.
- Ortho- or Neurosurgery (leg pain worse than back pain).
