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Flashcards in Lower Back Pain Deck (32):

Epidemiology of Lower Back Pain (2)

28% suffer from LBP1

Back pain: second Most common disability and retirement from work force as of 2009


First 2 reasons why people will see their "doctor"

respiratory tract infection
#2= MSK complaints


Lower back pain definition (4)

Pain felt in your lower back.

Spine, muscles, nerves, ligaments or other structures.

Can radiate from other areas.

LBP can be acute or chronic as defined by
3 months or longer

multifactorial biopsychosocial pain


Lower Back pain Radiographically characterized by:

Disc space narrowing-vacuum phenomenon
Subchondral cyst formation
Osteophyte formation


Lumbar Spine X-Rays

AP and lateral L-S spine
Routine films

2. Obliques
Look for spondylolysis (pars interarticularis fx)

3. Flexion and Extension
Look for unstable spondylisthesis


Indications for x-ray with lower back pain

Age > 50 years
No improvement after 6 weeks
History of trauma
Worrisome clinical finding such as very focal bone pain worse at nighttime


indications for MRI with lower back pain (2)

1. After 6 weeks if presence of sciatica
2. Interpret results with caution, as bulging discs are present on MRI or CT in more than half of
asymptomatic subjects. Correlate with physical exam.


Process of Central Spinal stenosis

Posterior disc bulge

Congenital narrow canal

Disc herniation


Combination of any above


Spondylolysis, "scotty dog fx"

This condition occurs in childhood and has risk factors of football players and in girls who are gymnasts. This lysis can eventually result in spondylolithesis where one vertebra slips forward on another.

Risk factors associated with development of this condition in non-athletes include:
Aging-obesity, lordotic angle and pelvic inclination were found to be individual risk factors for women and obesity the major risk factor for men for Lumbar Spondylolysis.


neurologic screen for lower back pain

SLR (straight leg raising)
Manual muscle test (MMT),
Sensation to light touch

If no improvement in 4 to 6 weeks

Consider psychosocial factors


Nerve root compression with L2 will have?

Decreased hip flexor strength


Nerve root compression with L3 will have?

Decreased patellar reflex; sensation loss of the anterior thigh; weakness in quadriceps muscle; pain in the area of the anterior thigh


Nerve root compression with L4 will have?

Sensory loss of the anterior lateral or medial foot; possible decreased patellar tendon reflex; weakness of the quadriceps; pain in the area of the anterior leg


Nerve root compression with L5 will have?

Sensory loss in the dorsum of the foot and great toe; weakness of the anterior tibialis, great toe (extensor hallicus longus), and hip abductors; pain down the side of the leg


Nerve root compression with S1 will have?

Decreased Achilles’ reflex; sensory loss of the lateral foot and the small toe; weakness of the gastrocnemius, gluteus maximus, plantar flexor, and great toe; pain down the back of the leg into the bottom or side of the foot


What is cauda equina syndrome?

Urinary retention with overflow incontinence

Saddle anesthesia

paralysis without spasticity

Massive midline disc herniation or tumor compresses the descending lumbosacral nerve roots.


Risk Factors for Lower back pain

Work in construction
Heavy lifting
Lots of bending and twisting
Whole body vibration
Have bad posture
Over age 30
Smoke, don't exercise, overweight
Have arthritis or osteoporosis
Have a low pain threshold
Feel stressed or depressed


Red Flags for lower back pain

Age >50
Significant trauma
Neurologic deficit
Weight loss (unexplained)
Substance abuse
Ankylosing spondylitis
Night pain
Malignancy Hx
Systemic steroids
Fever (>100º F)
Persistent pain
Compensation issues
Increased pain when recumbent
Bowel and bladder dysfunction


Different causes of lower back pain

. Idiopathic 70%
“Lumbar strain/sprain”
2. Degenerative disks and facets 10%
3. Herniated disks 2% to 4%
4. Spinal stenosis 3%
5. Osteoporotic compression fracture 4%
6. Spondylolisthesis


Leg Pain Greater Than Back Pain: Herniated Nucleus pulposus with Lumbar Radiculopathy

Referred neurogenic pain in the distribution of a lumbar (or cervical) nerve root or roots, with or without associated numbness, weakness, or loss of reflexes

• The irritating inner disc material (nucleus pulposus) escapes the disc and impinges an adjacent nerve root

• Positive straight leg raise

• Pain or paresthesia that radiates in a dermatomal pattern typically down the posterior or lateral leg and past the knee

• Loss of the respective reflex

• Symptoms worse with sitting, better with recumbency or standing


Leg Pain Greater Than Back Pain: Spinal Stenosis:

– Canal is wider when seated and becomes more narrow with standing

– Therefore the patient can walk a farther distance and remain
standing for a longer period if bent forward such as when pushing a shopping cart
– Symptoms in the legs when standing upright are often nondescript

• Legs feel “heavy” or “like rubber”
• Pain can be in a dermatomal distribution
• The clinical term of “spinal stenosis” is not used based on imaging
only. There must be symptoms of leg or buttock discomfort worse
on standing and improved on sitting.


What is spinal stenosis

Narrowing of the spinal canal secondary to
hypertrophic changes of the bone


What are the 6 differential categories








What are the rheumatologic differentials?

Ankylosing Spondylitis

Reiter’s Syndrome

Psoriatic Arthritis

Enteropathic Arthritis

DISH extra bones that develop along the vertebral bodies




Acute, Subacute, Chronic phases of lower back pain

Acute phase: up to 4 weeks
Control pain and minimize activity
but not bed rest

Subacute phase: 4 to 12 weeks
Control pain and maximize activity

Chronic: >3 months’ duration
Multidisciplinary interventions


Management Recommendations for Acute LBP

If no red flags
No investigation
No referrals
Reassure the patient
Symptom control
Avoid bed rest
Return to activity


Exercise to prevent lower back pain

There is strong evidence that exercise helps prevent LBP:
Strengthens the back muscles and increases trunk flexibility

Increases blood supply and thus minimizes injury and enhance repair

Improves mood

Has a positive effect on the perception of pain


Treatments for lower back pain (unsure of effectiveness)

Back schools
Epidural steroid injections
Lumbar supports
Transcutaneous electrical nerve stimulation (TENS)
Trigger point injections
Thermal therapy


Pharmacologic treatment for lower back pain

A. Anti-inflammatories
B. Tramadol
C. Opioids--> lack of response
D. Muscle relaxants


muscle relaxants

Muscle relaxants may promote healing by facilitating movement
Muscle relaxants may reduce the length of the acute stage
May prevent the development of an acute injury into a chronic condition
Effective alone or in combination with NSAIDs


advantages of muscle relaxants

- analgesic
- adjunctive therapy
- Short-term use does not cause complications, blood dyscrasia, or kidney problems
- Reduce pain-causing muscle spasms, hypertonicity, and rigidity


disadvantages of muscle relaxants

abuse potential