Scoliosis and Acute Low Back Pain

Question 1

Scoliosis is lateral curvature of the spine greater than ___ degrees with vertebral rotation

Answer 1

10

Question 2

What form is scoliosis most commonly found in?

Answer 2

Idiopathic (85%)

Question 3

Risk factors for progressive scoliosis

Answer 3

Female

Both parents have adolescent idiopathic scoliosis

Question 4

What population is recommended for screening for scoliosis?

Answer 4

Children and adolescents 10-18

Question 5

What is a positive Adam’s forward bend test?

Answer 5

Pt stands and bends at the waist, with a rib hump unilaterally because of spine rotation

Question 6

Why is screening for scoliosis a controversial topic?

Answer 6

Radiographs and referrals for scoliosis can lead to significant expense and risk of harm to patient and most scoliosis cases do not progress to clinically significant state

Question 7

What classifies as rapid curve progression in a patient with scoliosis?

Answer 7

Curve progression >1 degree per month

Question 8

What are the red flags associated with scoliosis?

Answer 8

Onset before age 8

Severe pain

Rapid curve progression > 1 degree per month

Unusual Left thoracic curve

Neurological defects (midline hairy patch, cafe au lait spots)

Question 9

Angle of trunk rotation greater than ___ degrees and Cobb angle of greater or equal to ___ degrees will determine if a pt needs radiography for scoliosis

Answer 9

ATR >7 degrees

Cobb > or equal to 10 degrees

Question 10

What is Risser sign?

Answer 10

Amount of ossification present in the iliac apophysis

Question 11

What grade would a Risser sign be if a scoliotic patient is more likely to progress in severity?

Answer 11

Grades 1-3

The less ossified bones are, the more likely a case will progress

Question 12

What is the curve angle for scoliosis that requires no active treatment?

Answer 12

Less than 10-15 degrees

Question 13

What is the curve angle for scoliosis in patients that may need a brace?

Answer 13

25-45 degrees

Question 14

What is the curve angle for scoliosis that needs surgery?

Answer 14

50 degrees

Question 15

When would a scoliotic curve cause pulmonary compromise?

Answer 15

>50 degrees

Question 16

When would a scoliotic curve cause cardiac compromise?

Answer 16

>75 degrees

Question 17

How is acute back pain classified?

Answer 17

6-12 weeks of pain between costal angles and gluteal folds

May radiate down one or both legs (sciatica)

Nonspecific

Question 18

What are the differential diagnoses for acute back pain of the intrinsic spine?

Answer 18

Compression fracture

Herniated nucleus pulposus

Lumbar sprain/strain

Spinal stenosis

Spondylolisthesis

Spondylolysis

Spondylosis

Question 19

What are the differential diagnoses for acute back pain that has spread systemically?

Answer 19

Connective tissue disease

Inflammatory spondyloarthropathy

Malignancy (pain in prone position)

Vertebral diskitis/Osteomyelitis

Question 20

What are the differential diagnoses for acute back pain that are referred?

Answer 20

Abdominal aortic aneurysm

GI conditions (retroperitoneal, peptic ulcer, and cholecystitis)

Herpes zoster

Pelvic conditions

Question 21

What are the 4 main red flags for serious etiology of acute low back pain?

Answer 21

Hx of Cancer

Hx of Cauda Equina

Fracture

Infection

Question 22

What are the red flags to look for in a patient’s history when they present with low back pain?

Answer 22

T - Trauma

U - Unexplained weight loss

N - Neurologic sx

A - Age >50 y/o

F - fever

I - IVDU (intravenous drug use)

S - Steroid use

H - History of CA

Question 23

Steps of a physical exam for acute low back pain?

Answer 23

Inspection

Palpation

Percussion (Lloyd’s punch)

ROM

Strength/sensation

Specialty testing

Question 24

What is the motor, sensory, and reflex innervation of L3?

Answer 24

Motor: Hip flexion

Sensory: Anterior/Medial thigh

Reflex: Patella

Question 25

What is the motor, sensory, and reflex innervation of L4?

Answer 25

Motor: Knee extension Sensory: Ant leg/Medial foot Reflex: Patella

Question 26

What is the motor, sensory, and reflex innervation of L5?

Answer 26

Motor: Dorsiflexion/Great toe Sensory: Lateral leg/Dorsal foot Reflex: Medial hamstring

Question 27

What is the motor, sensory, and reflex innervation of S1?

Answer 27

Motor: Plantar flex Sensory: Posterior leg/lateral foot Reflex: Achilles

Question 28

How does back strain present?

Answer 28

Onset with mild trauma (twisting) Muscle ache or spasm May become chronic Discrete tender points in lumbar tissue on exam No neurological defects

Question 29

How does Psoas Syndrome Present?

Answer 29

Shortening/spasm of iliopsoas muscle Dull ache in low back, sometimes refers to groin

Question 30

What is the main risk factor for psoas syndrome?

Answer 30

Desk jobs

Question 31

A herniated disc in the lumbar region will compress the nerve root of which vertebrae?

Answer 31

The vertebrae below

Question 32

How will herniated nucleus pulposus present?

Answer 32

Pain radiating down the leg (sciatica) Sharp burning pain - like electricity Weakness in affected myotome

Question 33

What is cauda equina syndrome?

Answer 33

Large, central disc herniation compressing tail of lumbar spine, compressing sacral nerve roots

Question 34

Impingement of what nerve roots in Cauda Equina syndrome cause bowel/bladder dysfunction, decreased rectal tone, and saddle anesthesia?

Answer 34

S2-S4

Question 35

A delay in surgery to treat cauda equina can result in what?

Answer 35

Irreversible paralysis

Question 36

Spondylolysis is caused by a defect in what?

Answer 36

Defect in par interarticularis without anterior displacement

Question 37

Spondylolisthesis is caused by what?

Answer 37

Vertebral body slips in relation to the one below at the pars interarticularis

Question 38

What is the management of low back pain for the first two visits?

Answer 38

1st visit: Patient education, avoid exacerbating movement, stay active, NSAIDs, muscle relaxant 2nd visit: Different NSAIDs, refer to PT, refer to spine subspecialist