Lower Back Pain

Question 1

How long does it take for most lower back pain problems to resolve?

Answer 1

2 to 4 weeks

Question 2

97% of all back pain

Answer 2

Mechanical

Question 3

Most common mechanical causes of back pain

Answer 3

Lumbar strain- 70%
Degenerative joint changes- 10%
Herniated disc- 4%

Question 4

Risk of low back pain

Answer 4

Prolonged sitting
Deconditioning
Poor lifting techniques
Repetitive lifting
Congenital causes
Obesity

Question 5

Red flags

Answer 5

Fever
Weight loss
Pain at night
Bowel or bladder issues
Neurological symptoms

Question 6

Classic disc herniation

Answer 6

Worse with sitting or bending
Better when laying or standing 
Others
- Radiation down leg
- Paresthesia
- Weakness

Question 7

Night pain or pain at rest is a red flag for

Answer 7

Cancer

Question 8

Hx of IV drug use is a red flag for

Answer 8

Infection

Question 9

Major muscle weakness or foot drop is red flag for

Answer 9

Significant herniated nucleus pulposus

Question 10

Chance of returning to work if out for 6 months? At 2 years?

Answer 10

50%

Almost 0

Question 11

Systematic order of performing a physical exam for back pain

Answer 11

Standing
Sitting
Supine

Question 12

Basic components

Answer 12

Inspection
Palpation
ROM

Question 13

Restriction or pain with flexion indicate

Answer 13

Herniation
OA
Muscle spasm

Question 14

Pain with extension

Answer 14

Degenerative disease

Spinal stenosis

Question 15

Pain on same side as lateral motion

Answer 15

Bone pathology (OA or compression)

Question 16

Pain on opposite side as lateral motion

Answer 16

Muscle strain

Question 17

Difficulty walking on heal

Answer 17

L5 herniation

Question 18

Difficulty walking on toe

Answer 18

S1 herniation

Question 19

Pain is reduced while squatting

Answer 19

Central spinal stenosis

Question 20

(+) tripod sign

- Modified straight leg test

Answer 20

Structural disease

Question 21

In what position should you do a neurological exam

• Reflexes
• Strength
• Sensation

Answer 21

Sitting

Question 22

What are the main nerve roots to focus on

Answer 22

L4 through S1

Question 23

Great toe

Answer 23

L5

Question 24

Lateral malleolus and posterolateral foot

Answer 24

S1

Question 25

4+ gradding on reflexes

Answer 25

Clonus

Question 26

Decreased patella reflex

Answer 26

L3 to L4 impingement

Question 27

Decreased achilles reflex

Answer 27

L5 to S1 impingement

Question 28

Hyper-reflexia

Answer 28

Upper motor neuron sign | - Spinal cord compression

Question 29

Hip flexion

Answer 29

L2 to L4

Question 30

Hip abduction

Answer 30

L4 to S1

Question 31

Hip adduction

Answer 31

L2 to L4

Question 32

Knee extension

Answer 32

L2 to L4

Question 33

Knee flexion

Answer 33

L5 to S2

Question 34

Dorsiflexion

Answer 34

L4 & L5

Question 35

Plantar flexion

Answer 35

S1 & S2

Question 36

Decreased strength

Answer 36

Nerve impingement

Question 37

Passive straight leg test

Answer 37

SLR or Lasegue's sign

Question 38

Pain with dorsiflexion (SLR)

Answer 38

Sciatic issue over tight hamstring

Question 39

Pain radiates down posterior/lateral side of leg

Answer 39

+ SLR | S1 or L5

Question 40

Pain if leg is raised less than 30

Answer 40

Malingering

Question 41

Pain on opposite side of raised leg

Answer 41

Significant nerve root compression due to central disc herniation

Question 42

Positive crossed leg raise | - Asymptomatic leg is raised

Answer 42

Significant central herniation | - .9 specificity, not great sensitivity

Question 43

Positive FABER | - Flexion, Abduction, & External rotation

Answer 43

Sacroiliitis

Question 44

Pain worse with movement and sitting

Answer 44

Suggestive of mechanical pain

Question 45

Pain radiating down leg & numbness

Answer 45

Suggest disc herniation

Question 46

Pain improves in supine position

Answer 46

Suggest spinal stenosis or herniation

Question 47

How soon should decompression done for cauda equina syndrome

Answer 47

72 hrs

Question 48

Localizable bony tenderness Dull, throbbing pain with slow progression Worse with recumbency or cough

Answer 48

Malignancy

Question 49

15 to 40 yr old | Morning stiffness and achiness over SI joint or lumbar spine

Answer 49

Ankylosing spondylitis

Question 50

Aching back and posterior thigh discomfort | Increases with activity or bending

Answer 50

Spondylolisthesis

Question 51

Studies for low back pain

Answer 51

CBC: Cancer of infection X-ray: Specific guidelines Lumbar Spine Film: Specific guidelines MRI: Specific guidelines

Question 52

X ray

Answer 52

``` Trauma Osteoporosis or Steroid use 70 Cancer or signs of cancer Pain worse when supine or severe at night ```

Question 53

Lumbar spine

Answer 53

``` > 50 Trauma Neurological deficits Weight loss Hx of ankylosing spondylitis Drug or alcohol abuse Hx of malignancy Fever No improvement (no financial compensation) ```

Question 54

MRI

Answer 54

``` Neurological deficits Radiculopathy Progressive motor weakness Cauda equina Systemic disorders Failed 6 weeks of conservative care ```

Question 55

Bottom line of imaging

Answer 55

If no red flags are present do not image until 6 weeks

Question 56

Therapy for back pain

Answer 56

NSAIDs Local therapy (Hot/Cold) Normal activity PT (?)

Question 57

Options if pain has no resolution follow appropriate conservative management

Answer 57

Refer to spine surgeon or pain clinic - Progression or poor pain control Continue conservative treatment (If no red flags) - Ok to DC PT if patient has been getting and not had relief