Low Back Pain and Leg Pain Flashcards
(38 cards)
What is the critical factor in assessing patients with lower back pain?
Features of lumbosacral nerve root compression such as leg pain or focal signs of neural compression in lower limbs.
What causes sciatica?
Most commonly by lumbar disk prolapse Osteophytes Lumbar canal stenosis Spondylolisthesis Tumors are rare (cauda equina or pelvic)
What are the most common lumbar levels for disk prolapse?
L5/S1 (75%)
L4/L5 (20%)
Why is disc herniation usually in a posterolateral direction?
PLL (posterior longitudinal ligament) prevents direct posterior herniation.
What is the difference between a posteromedial prolapse vs lateral prolapse?
- Posteromedial causes compression of lumbar nerve root passing across the disc to enter the neural canal BELOW pedicle
- Posterolateral causes compression on nerve root passing beneath pedicle ABOVE prolapse
What is presentation of patient with sciatica?
- Obvious discomfort
- Lies tilted to side opposite of sciatica
- Affected hip/knee slightly flexed taking pressure off stretched nerve
- Pain worse with straining
- Pain radiating to buttocks, posterolateral calf and foot (S1) or dorsum of foot and great toe (L5)
- Pain along anterior thigh (L3)
- Pain along anterior leg/shin (L4)
- Check sphincter tone as large may cause cauda equina compression
Important PE in sciatica?
- Straight leg testing on affected side
- Head to toe neuro exam
- Look for muscle wasting
- For plantarflexion weakness ask to stand on tippy toes
- DTRS!
- Rectal exam
Segmental innervation of hip flexors, adductors, medial rotators?
L1, L2, L3
Segmental innervation of hip extensors, abductors, lateral rotators?
L5, S1
Segmental innervation of knee extensors?
L3, L4
Segmental innervation of knee flexors?
L5, S1
Segmental innervation of ankle dorsiflexors?
L4, L5
Segmental innervation of ankle plantarflexors?
S1, S2
Segmental innervation of foot invertors?
L5, S1
Segmental innervation of foot evertors?
L5, S1
Segmental innervation of intrinsic foot muscles?
S2, S3
Describe clinical features of L5/S1 prolapsed disc?
- Pain along posterior thigh with radiation to heel
- Weakness of plantar flexion
- Sensory loss in lateral foot
- Absent ankle jerk
Describe clinical features of L4/L5 prolapsed disc?
- Pain along posterior or posterolateral thigh with radiation with radiation to dorsum of foot and great toe.
- Paresthesia and numbness of dorsum of foot/great toe
- Reflex changes unlikely
Describe clinical features of L3/L4 prolapsed disc?
- Pain in anterior thigh
- Wasting of quads muscle
- weakness of quads function and dorsiflexion of foot
- Diminished sensation over anterior thigh, knee and medial aspect of lower leg
- Reduced knee jerk
Management of bulging disc vs. nucleus pulposus that has herniated out of disc space?
- bulging disk does well with conservative treatment
- nucleus pulposus herniation most likely need surgery
Describe important features of conservative treatment for disc herniation?
- should improve in 7-10 days (bed rest), with NSAIDs
- spinal manipulation is NOT recommended
- Resolution 2/2 to resorption of prolapsed disc material, edema of nerve decreasing and possible adaptation of pain fibres to pressure.
Investigations for low back pain?
- Lumbar spine XR (excludes spondylolisthesis, tumor)
- ESR (excludes systemic disease)
- (MRI if does not improve after conservative management and/or if see Red Flags!)
Indications for surgery re: low back pain?
- Pain (incapacitating despite bed rest, recurrent pain despite adequate relief with bed rest)
- Neurological deficit (significant weakness, increasing weakness)
- Central disk prolapse (bilateral sciatica, sphincter disturbance, diminished perineal sensation – EMERGENCY!)
Surgical options for disc prolapse?
- Typically laminectomy, occasionally disc prolapse excision.
- Bulging disk = conservative tx, sometimes percutaneous disectomy helpful
- Bulging nucleus pulposus = percutaneous disectomy not helpful
