Low Back Flashcards
(43 cards)
What % of LBP is due to serious disease? What are the diseases?
3%
1% = local cancer or spinal infection
2% = referred pain from viscera (usually from GI, reproductive system or urinary)
What ancillary studies should you order if you suspect disease?
- plain film - MRI, CT, or bone scan (looking for accumulation of black)
- order ESR (or CRP) and CBC
- if cancer or infection is suspected consider blood chemistry panel (calcium, ALP, protein)
- if arthritic condition (anti-CCP, RF, ANA, HLA-B27)
Focusing on primary care patients, Von Korff (1996)
challenged the belief that __% of LBP resolved in
approximately __ weeks.
90%
3
He demonstrated that the course of back pain is
complex, with frequent recurrences.
About __% of patients continued to experience
_______________________ pain, either intermittently or
continuously at one year.
33%
Moderate or intense pain
About ___% reported important _______________
in the long term. Studies since then have
demonstrated similar results. (Chou 2010)
20%
functional limitations
What are the 5 clues for nerve root assessment?
History
- Leg pain (dermatomal? quality? More
intense than the LBP?)
- Dermatomal paresthesia
Physical Exam
- Lumbar tension tests
- Neurological deficits/abnormalities
- Any other lumbar joint loading procedure that causes immediate leg sx
What are cauda equine syndrome signs and symptoms? What are important SN and SP?
- Urinary RETENTION (90% sensitivity, 95% Assumed
specificity, LR+ = 18; LR– = 0.1) and/or INCONTINENCE (high sensitivity) - Altered sensation in SADDLE DISTRIBUTION (75%
sensitivity) - Diminished SEXUAL FUNCTION
- Diminished anal SPHINCTER TONE (60-80% sensitivity)
*Other findings that may be there incidentally: Possible unilateral/, BILATERAL SCIATICA, positive SLR, other sensory/motor deficits (80% sensitivity for at least one of these).
What is the single best muscle test to check for an L5 here root compression (radiculopathy)? *****
Hip abduction (LR 95% CI, 1.3-84)
What is essential to chart about radiculopathy? What is optional to chart
Essential
- where the pain is radiation
- angle the leg was raised
Optional
- quality of pain
- Severity (1-10)
- reproduces symptoms
- other symptoms
If a SLR is a hard positive, what tests should you do next?
Confirm with
- braggard (sensitivity 71%)
- bowstring (sensitivity 69%)
- bonnet (internal rotation and adduction) OR (seated SLR/ Bechterew)
If a SLR is a soft positive, what tests should you do next?
See if you can increase the pain into the foot
- Maximum SLR
- Seated SLR (bechterew)
If a SLR is a negative, what tests should you do next?
- maximum SLR
- assess hamstrings
- assess lumbars, hip and SI
What angle of SLR is a positive?
Generally between 30-60 degrees
- >35-<45 may be more specific for herniation (especially non-contained)
Is seated SLR/Bechterew is positive, what test should you do next
- seated bowstring (Deyerle’s)
- slump test (seated max SLR)
What nerve root is the Femoral stretch test testing? Which peripheral nerve? What is another name for this test? What does a positive tell you?
L2-4 and femoral nerve
“Reverse SLR”
- may be positive for L4 hen SLR is negative
- may be positive for foramina/far lateral disc herniation
What are extra-spinal causes of sciatica?
- Piriformis syndrome
- Pelvic/gynecologic conditions (INCLUDING ENDOMETRIOSIS)
- Herpes zoster (shingles)
- Diabetic neuropathy
- HIV/Lyme disease neuropathy
- Pregnancy/delivery (prolonged time in lithotomy position)
- Trauma to nerve or surrounding structures (hip/pelvis/biceps femoris)
What is the common ancillary study ordered for extra-spinal causes of sciatica?
CATscan of the pelvis
What is the peak age for disc herniation in the lumbar spine? Where is the most common location?
- Peak incidence at ages 30-55 years (other sources say 20-40)
- 95-98% of clinically important lumbar disk herniations at L4-L5 or L5-S1
Which lumbar disc herniations should definitely get and MRI?
Upper lumbar disc until L4???????
After lumbar stenosis, fracture, and spondylolistheses have been ruled out, LUMBAR DISC HERNIATION accounts for about ___% of patients with sciatica
85%
What are the clues for a disc herniation
- Sx centralization with repetitive/sustained loading - Decreased sagittal thoracolumbar ROM - Positive Valsalva - Sitting poorly tolerated - DeJeurine’s triad - Flexion load sensitivity - Sensitive to axial loading (e.g., dSLR) - Positive XSLR (well leg) - Mannequin sign*
What are clues for disc derangement?
Sx centralization with repetitive/sustained loading - Decreased sagittal thoracolumbar ROM - Positive Valsalva - Sitting poorly tolerated - DeJeurine’s triad - Flexion load sensitivity - Sensitive to axial loading (e.g., dSLR)
Which clues are for disc herniation but NOT for disc derangement?
- Positive XSLR (well leg)
- Mannequin sign*
What is the strongest single clue for disc herniation?
Positive XSLR (well leg)
