Leading cause of disability in young people
Low back pain
What does the designation "chronic" mean for low back pain
Persisting beyond 3 months and affects 15-45% of the population
- Anterior longitudinal ligament - Posterior longitudinal ligament (weaker of these two) - Ligamentum flavum, which joins adjacent laminae - Supraspinous ligament
Tapered end of the spinal cord which occurs at about L1 to L2
Has dorsal and ventral roots that join together in the intervertebral neuroforamen to become the spinal nerves
Description of why/how flexing and extending the back can cause pain
Important portion of the disc is the nucleus pulposus, which becomes looser with conditions like rupture and herniation. Remember from Physical exam small group that when we have a problem with flexing the back (leaning forward), which involves an anterior vertebral compression, we are pushing the disc outward. In a compromised disc, the goop (nucleus pulposus) pushes back against the nerves, causing bad pain. With extension problems, we know the issue is boney. Why? Because we have a posterior compression, the vertebrae are crunching posteriorly, and if there is pain, we know there is arthritis, a fracture, something like that. These patients tend to want to be bent over.
Problems with the nucleus pulposus is caused do to a break in integrity of the annulus fibrosus, the layer surrounding the nucleus pulposus that protects it from herniating and rupturing
Flexion typically occurs where?
80-90% of flexion occurs at L5-S1 and L4-L5
Weakest part of the spine?
The disc is the weak link. Slow degeneration and shrinkage of the disc leads to decreased tension of the anterior and posterior longitudinal ligaments (ALL & PLL) This produces segmental dysfunction and instability.
What happens to the rest of the vertebrae once we have a weakened disc
Weight gets shifted from the anterior elements (disc/vertebral bodies) to the posterior elements (facets). The anterior instability leads to calcification (spur formation) of the ALL & PLL.
What happens with increased shift to the posterior elements of the spine?
Increased weight shift to the posterior elements leads to osteoarthritic changes of the facets (as discussed above with the nucleus pulposus) with associated spur formation and stenotic changes. All this extra calcium deposition leads to ankylosis and thus, stabilization of the segmental instability.
Can we get nerve pain even with no compression directly on the nerve?
aqueous contents (Phospholipase Alpha-2 being the most well known) of the disc are noxious to the nerve.
When do we see an inflammatory response after the nerve is exposed to the nucleus pulposus?
Inflammatory changes occur within 5 days of exposure of the nerve to nucleus pulposus contents.
Releationship between size of herniation and symptoms?
What are the 7 points in retrieving a History for low back pain?
- Onset of pain
- Location of pain
- Type/Character of pain (sharp, dull, etc)
- Aggravating and relieving factors
- Medical history that includes previous injuries
- Psychosocial stressors at home or work
- Evidence of systemic disease
What are some indications of inflammatory low back pain?
There are 4
- Alternating buttock pain
- Morning stiffness lasting greater than 30 minutes
- Alleviated with use, aggravated by rest
- Pain in the second half of the night
How long should back pain occur without red flags before imaging is indicated?
What percentage of low back pain gets better on its own when red flags are absent and there is no sciatica?
How long is bed rest recommended for low back pain?
Only 24-48 hours, longer seems to be counterproductive
What are some indications for surgical referral of low back pain?
There are 6
- Progressive motor weakness
- Bowel or bladder disturbance
- Incapacitating nerve root pain despite conservative treatment for at least 4 weeks
- Recurrent incapacitating pain despite conservative treatment
- Suspected cord compression
- Cauda Equina Syndrome signs
What are some symptoms of umbar spinal stenosis?
Symptoms of significant lumbar spinal stenosis include back pain, transient tingling in the legs, and ambulation-induced pain localized to the calf and distal lower extremity, resolving with rest (especially sitting or spinal flexion). This pain with walking, referred to as "pseudoclaudication" or "neurogenic claudication", is clinically distinguished from vascular claudication by the presence of normal arterial pulses.
What are some symptoms consistent with cauda equina syndrome?
5 listed here
- Severe back pain
- Saddle Anesthesia
- Lack of an Achilles reflex
- Sexual dysfunction
Sciatica with disc herniation is typically worsened by what?
What is one maneuver we can use to test this?
Worsened by sneezing or coughing
May have patients perform the Valsalva maneuver