Lower Back Pain

Question 1

In the lying position, the pressure on the discs is ____ kg
when standing or walking ___ kg
when sitting ___ kg
when lifting a load ____ kg

Answer 1

In the lying position, the pressure on the discs is 25-75 kg
when standing or walking 100 kg
when sitting 135-180 kg
when lifting a load 275 kg

Question 2

List risk factors for lower back pain (5)

Answer 2

1. repetitive actions
2. vibrations
3. cigarettes (osteoporosis)
4. massive thickness
5. major skeletal abnormalities
   degenerative changes caused by disc aging

Question 3

Major skeletal abnormalities leading to lower back pain (3)

Answer 3

1. scoliosis >40%
2. spinal stenosis
3. ankylosing spondylosis

Question 4

Degenrative changes caused by disc aging (2) that lead to lower back pain

Answer 4

1. descrease nucleus pulposus
2. thickening of the annulus fibrosus

Question 5

Anamnesis for lower back pain

Answer 5

1. mechanism of pain/injury
2. duration, quality, and spread of pain
3. precipitating factors
4. facilitating and aggravating factors
5. previous history of back problems
6. other diseases/injuries
7. medicines

Question 6

What is relationship between history of malignancy and back pain?

Answer 6

In patients with a personal history of cancer, new back pain should be considered malignant until proven otherwise

Question 7

Most commong cause of low back pain according to age:
>50
>65
>70
<40

Answer 7

> 50 malignancy
65 abdominal aortic aneurysm in a male current or former smoker
70 compression fracture with or without trauma
<40 ankylosing spondylitis

Question 8

What could be a possible reason for low back pain for someone who has previously been treated with corticosteroids for more than 1 month?

Answer 8

Compression fracture

Question 9

What could be a possible reason for low back pain for someone who uses injection drugs or has a current infection?

Answer 9

osetomyelitis or paraspinal abscess

Question 10

what is the cause of pain: low back pain, but pain remains above the knee

Answer 10

hip pathlogy

Question 11

what is the cause of pain: low back pain, but pain radiates down the leg below the knee

Answer 11

sciatica (irritation or compression of the L4-L5, S1, nerve roots, usually from a disk herniation)

Question 12

what is the cause of pain: low back pain, but pain is localized in the abdomen or pelvis

Answer 12

visceral source

Question 13

diagnosis: low back pain, but pain is electrical or shock-like

Answer 13

disk herniation

Question 14

diagnosis: low back pain, pain is constant and nocturnal

Answer 14

malignancy when worse with rest
mechanical when improved with rest

Question 15

low back pain, pain is colicky

Answer 15

referred pain from a visceral organ

Question 16

pain with tearing/ripping quality

Answer 16

aortic dissection

Question 17

diagnosis of cyclical low back pain

Answer 17

endometriosis

Question 18

low back pain that has been persisten and progressive for over 1 month, older pt

Answer 18

malignancy in older pt

Question 19

low back pain that has been persistent an progressive for over 3 months, younger pt

Answer 19

ankylosing spondylitis

Question 20

low back pain worse in the morning and associated with morning stiffness

Answer 20

ankylosing spondylitis

Question 21

pain in the legs with standing that increases with cough or walking

Answer 21

neurogenic claudication from spinal stenosis

Question 22

low back pain that imrpoves with forward bending or sitting

Answer 22

spinal stenosis or spondylolisthesis

Question 23

low back pain that improves with excersice

Answer 23

ankylosing spondylitis

Question 24

low back pain that worsesn with bending forward or sitting

Answer 24

disk herniation

Question 25

if there is some connection to eating pattern (improves/worsens after eating, vomiting, nausea), low back pain is due to

Answer 25

GIT

Question 26

low back pain + fever

Answer 26

osteomylitis, malignancy, infection related to intra-abdominal or pelvic eitology

Question 27

physical exam of low back pain includes: (4)

Answer 27

1. inspection 2. palpation 3. specific tests 4. neurologic examination

Question 28

inspection during physical exam of low back pain include:

Answer 28

1. walk 2. position 3. scoliosis 4. kyphosis 5. lordosis

Question 29

palpation of low back pain during physical exam includes

Answer 29

1. paravertebral musculature 2. spiny appendages 3. sacroiliac joints 4. abdominal palpation

Question 30

List specific tests for low back pain (4)

Answer 30

1. movement in 4 directions 2. leg lift 3. PAtrics - FABRE test 4. Valsava maneuver

Question 31

Describe test movement in 4 directions

Answer 31

anteflexion, retroflexion, lateroflexion, rotation

Question 32

ICD-10 for low back pain

Answer 32

M54. 5, referred to as "lumbago"

Question 33

What does "FABRE" stand for?

Answer 33

F - FLEXION of the hip and knee on the painful leg AB - ABDUCTION of the leg ER - EXTERNAL ROTATION of the knee (heel to the knee of the healthy leg) E - EXTENSION (fix the opposite hip and press the knee)

Question 34

FABRE test: back pain

Answer 34

compression fracture

Question 35

FABRE test: pain in the sacroilliac joint

Answer 35

pathology in that joint

Question 36

FABRE: hip pain

Answer 36

degenrative changes in the hip joint

Question 37

FABRE: pain spreads towards the toes

Answer 37

radiculopathy

Question 38

FABRE: no pain

Answer 38

other etiology

Question 39

Neurological exam of low back pain consists of

Answer 39

1. position 2. muscle strength 3. sensibility 4. reflexes

Question 40

what reflexes do we check with low back pain

Answer 40

1. anal 2. cremasteric 3. patelar 4. achilles

Question 41

Describe: L5-S1 disc herniation (S1 nerve root): (50% of cases)

Answer 41

Pain radiation: into posterior thigh, posterior and lateral calf, and heel Sensory deficit: posterior calf, and lateral aspect of foot Motor deficit: plantar flexors – have patient walk on toes Reflex deficit: ankle

Question 42

Describe: L5-S1 disc herniation (S1 nerve root): (50% of cases) pain radiation, sensory deficit, motor deficit, reflex deficit

Answer 42

Pain radiation: into posterior thigh, posterior and lateral calf, and heel Sensory deficit: posterior calf, and lateral aspect of foot Motor deficit: plantar flexors – have patient walk on toes Reflex deficit: ankle

Question 43

Describe : L4-5 disc herniation (L5 nerve root): (40% of cases) pain radiation, sensory deficit, motor deficit, reflex deficit

Answer 43

Pain radiation: into lateral thigh, anterior calf and dorsum of the foot, +/- great toe Sensory deficit: anterior calf, dorsum and medial aspect of foot, first web space, +/- great toe Motor deficit: dorsiflexors - have patient walk on heels, or dorsiflex great toe against resistance Reflex deficit: none

Question 44

Describe: disc herniation (L4 nerve root): (10% of cases) pain radiation, sensory deficit, motor deficit, reflex deficit

Answer 44

Pain radiation: into lateral and anterior thigh, medial calf, medial foot, +/- great toe Sensory deficit: medial calf and foot, +/- great toe Motor deficit: Quadriceps Reflex deficit: knee

Question 45

should we order imaging for sciatica according to NICE2016

Answer 45

let specialists decide that, do not order it routinely

Question 46

Treatment of low back pain

Answer 46

NON-PHARMACOLOGICAL (CORRECT ATTITUDE AND POSTURE) PHARMACOLOGICAL (NSAIDs, muscle relaxant, aggravating activities) If the symptoms persists beyond 4 weeks, physical therapy should be considered; MRI (if radicular symptoms become bothersome)

Question 47

Steps for pharmacological therapy of low back pain

Answer 47

1. NSAIDS (Take into account GIT, liver, cardiotenal toxicity) at lowest effective dose 2. weak opioids (with ot without paracetamol) 3. do not offer paracetamol alone 4. do not offer: opioids for chronic pain, SSRI, SNRI or TCA, gabapentinoids or antiepileptics

Question 48

low back pain red flags ( a lot of them, just read)

Answer 48

Progressive neurologic deficit Recent bowel or bladder dysfunction Saddle anesthesia Traumatic onset Age > 50 Male with diffuse osteoporosis or compression fracture Cancer history Insidious onset No relief at bedtime or worsens when supine Constitutional symptoms (e.g. fever, weight loss) Hx UTI/other infection, IV drug use, TB exposure Immune suppression, Steroid use history Previous surgery