Case 10: Low Back Pain Flashcards Preview

Family Medicine > Case 10: Low Back Pain > Flashcards

Flashcards in Case 10: Low Back Pain Deck (50):
1

Most back pain resolves within...

two to four weeks

2

Congenital causes of lower back pain

Kyphosis (curved forward)
Scoliosis
Spondylolysis (Scotty dog fracture)

3

Traumatic causes of lower back pain

Lumbar strain
Compression fracture

4

Metabolic causes of lower back pain

Osteomalacia
Hyperparathyroidism
Paget's disease
Osteoporosis

5

Infectious causes of lower back pain

Pyelonephritis
Osteomyelitis
Discitis
Herpes zoster
Epidural or spinal abscess

6

Inflammatory causes of lower back pain

Ankylosing spondylitis
Sacroilitis
Rheumatoid arthritis

7

Neoplastic causes of lower back pain

Multiple myeloma
Metastatic disease
Lymphoma
Leukemia
Osteosarcoma

8

Degenerative causes of lower back pain

Disc herniation
Osteoarthritis
Facet arthropathy
Spinal stenosis

9

Vascular causes of lower back pain

Aortic aneurysm
Diabetic neuropathy

10

Visceral causes of lower back pain

PID
Prostatitis
Endometriosis
Kidney stones
Pancreatitis
Cholecystitis
Ovarian cyst

11

3 major categories of back pain

1. Mechanical (97%) - from bones, muscles, nerves
2. Visceral (from internal organs)
3. Non mechanical

12

3 most common causes of back pain

All mechanical
1. Lumbar strain/sprain (70%)
2. Age related degenerative joint changes
3. Herniated disc

13

RFs for lower back pain (5)

1. Prolonged sitting (truck driver, desk job)
2. Deconditioning
3. Sub optimal lifting and carrying habits
4. Repetitive bending and lifting
5. Spondylolysis, disc space narrowing, spina bifida

14

Red flags for serious illness or neuro impairment with back pain (5)

- fever
- unexplained weight loss
- pain at night
- neuro symptoms
- bowel or bladder incontinence

15

Disc herniation is worse with and better with?

Worse with sitting, leaning forward
Better with lying down or standing

16

Symptoms of disc herniation (4)

- increased pain with coughing/sneezing/valsalva
- radiation of pain down leg/foot
- paresthesias
- muscle weakness (foot drop)

17

Consider significant herniated nucleus pulposus

- major muscle weakness (=3 out of 5 strength)
- foot drop

18

Consider cauda equine syndrome if

- urinary incontinence or retention
- saddle anesthesia
- fecal incontinence
- bilateral LE weakness or numbness
- progressive neuro deficits

19

Prolonged use of corticosteroids increases probability of ______ ________ as source of LBP

Vertebral fracture (as does trauma, age >70, osteoporosis)

20

Recurrence of back pain is

High at 35 to 75%

21

Physical exam for LBP has 3 components

- standing
- sitting
- supine

22

Standing LBP physical exam

1. Inspection for lordosis, kyphosis, scoliosis
2. Palpation
3. Range of motion: lumbar flexion, lumbar extension, lateral motion
4. Gait: heel walk (L5) and toe walk (s1)
5. Stoop test (go from standing to squatting) - in central spinal stenosis, squatting will reduce the pain

23

Seated LBP physical exam

1. Check for CVA tenderness
2. Modified straight leg raise test
3. Neurological exam (to assess for nerve root impingement syndromes)

24

Modified straight leg raise test in seated LBP physical

Raise each leg while talking to pt
- if pain is functional, action is possible w/o difficulty
- if pain is structural, person will instinctively tripod (lean backward and support self with arms)

25

2/5 strength

Voluntary movement in plane of gravity

26

3/5 strength

Movement against gravity

27

4/5 strength

Movement against some resistance

28

L3

Patellar reflex
Sensation: lateral thigh
Motor: extend quads (squat down and rise)

29

L4

Patellar
Sensation: medial calf/ankle
Motor: dorsiflex foot (walk on heels)

30

L5

Sensation: lateral calf, dorsum of foot, big toe
Motor: dorsiflex big toe (walk on heels)

31

S1

Achilles reflex
Sensation: posterior calf, sole of foot, lateral ankle
Motor: Plantar flex ankle (walk on toes)

32

Supine LBP physical exam

1. Abdominal exam (AAA, tenderness)
2. Rectal exam only if there are alarm symptoms - look for bleeding or decreased done
3. Passive straight leg test
4. Crossed leg test
5. FABER test
6. Pelvic compression test
7. Observe muscle atrophy

33

Straight leg test

Sensitive, but not specific (a negative test makes herniated disc unlikely)
Normal leg can be raised 80 degrees - + test if
- leg raised <80 degrees: sciatica (+ pain w dorsiflexion) or tight quads (no pain w dorsiflexion)
- pain that radiates down leg (disc herniation)
- pain in opposite leg (root compression due to central disc herniation)

Less sensitive and specific test than MRI

34

Crossed leg test

Raise asymptomatic leg
+ test if pain in contralateral leg: highlights degree of disc herniation - if positive, large central herniation present

35

FABER test

positive test indicates sacroiliitis

36

Pelvic compression test

Forcibly press hips together - positive test indicates sacroiliitis

37

Differential Dx for LBP

1. Lumbar strain
2. Disc herniation
3. Degenerative joint disease
4. Spinal stenosis
5. Cauda equine syndrome
6. Pyelonephritis
7. Malignancy
8. Ank spondy
9. Spondylolisthesis
10. Prostatitis
11. Pancreatitis
12. Spinal fracture

38

Pain worse with movement or sitting

Think mechanical cause
- lumbar strain
- disc herniation
- degenerative arthritis

39

Cauda equine syndrome

- due to large mass effect - acute disc herniation compresses the cauda equine - pain radiates down leg with numbness + bladder/bowel incontinence
- if present, DECOMPRESSION IN 72 HRs (surgical emergency)

40

Malignancy as cause of LBP

Pain localized to affected bones: dull, throbbing pain that progresses slowly that increases with cough
- seen in pts > 50

41

Ank spondy

Chronic, painful inflammatory arthritis primarily affecting spine and SI joints
-pts 15 to 40 yrs old
- Morning stiffness that improves with activity

42

Spondylolisthesis

Anterior displacement of vertebra or vertebral column
- any age
- aching back and posterior thigh discomfort that increases w activity or bending

43

Is early MRI associated with improved outcomes in patients with acute back pain or radiculopathy?

No!
75% of herniated discs improve with 6 weeks of conservative therapy

44

In absence of red flags or findings suggestive of systemic disease, diagnostic testing, is ...

Not indicated until after 4-6 weeks of conservative management

45

Radiation exposure to ovaries in a single plain Xray of lumbar spine is equal to

Getting a daily chest Xray for more than a year

46

Conservative Tx for acute low back pain

- NSAIDs, acetaminophen, muscle relaxants
- local therapy with heat/cold
- NO bed rest- resume regular activities!

47

Referral to surgeon or advanced imaging (MRI/CT) should be considered if

Pain does not improve in 4-6 weeks or if neuro deficits appear/progress
- can also refer to pain clinic for epidural spinal injection

48

Opioids are

second line treatment for back pain
(and oral steroids are never the answer)

49

PT for LBP?

Some data shows that tailored PT is more effective for acute back pain compared to pts who just stay active

50

Acupuncture for LBP?

Limited evidence