1
Q
This is the term for low back pain symptoms that usually last less than 4 weeks but can be up to 3 months. Also defined as 6-12 weeks of pain between costal angles and the gluteal folds that may radiate down one or both legs.
A
Acute Lower Back Pain
2
Q
This is the term for lower back pain lasting longer than 3 months.
A
Chronic Lower Back Pain
3
Q
This is the term for leg pain that localizes to the lumbar sacral nerve roots. 90% at L4-L5 and L5-S1.
A
Sciatica
4
Q
This is the term for degenerative arthritis of the spine.
A
Spondylosis
5
Q
This is the term for a defect in parts of the interarticularis.
A
Spondylolysis
6
Q
The is the term for vertebra(e) that slips out of position in relationship to the vertebra immediately inferior to it.
A
Spondylolisthesis
7
Q
On a CXR you notice a Scotty dog image. What is this indicative of?
A
Spondylolysis
8
Q
This is the term for compression of the equina that effects the lower limbs and can cause neurogenic bladder, loss of rectal tone, and saddle anesthesia.
A
Cauda Equina Syndrome
9
Q
This is the term for crowding of the spinal canal which can cause nerve root and spinal cord compression. Could be caused by osteoarthritis, ligamentous thickening, bulging intervertebral discs.
A
Spinal Stenosis
10
Q
This is the term for an inflammatory condition that effects the spinal cord.
A
Myelitis
11
Q
This is the term for lesions in the conus medullaris which can cause increased tone and reflexes.
A
Conus Medullaris Syndrome
12
Q
This is the term for compressed or irritated nerves which results in pain, numbness, tingling, or weakness along the course of the nerve.
A
Radiculopathy
13
Q
This is the term for “muscle and its nerve”
A
Myotome
14
Q
This is the term for the area of the skin supplied by nerve fibers originating from a single dorsal nerve root.
A
Dermatome
15
Q
______ and _____ leads to recurrent tears in the annulus fibrosis of discs.
A
Activity; Aging
16
Q
Effects of biomechanical stress increases on the body:
A
- Bone Overgrowth
- Facet Hypertrophy
- Thickening of Ligaments
- Decreased size of the spinal canal
- Narrowed foramina
- Impingement of the spinal nerve roots
17
Q
Mechanical Causes of Low Back Pain
A
- Lumbar strain or sprain (70%)
- Degenerative Disk or Facet Dz (10%)
- Herniated Disk (4%)
- Osteoporotic Compression Fracture (3%)
- Spondylolisthesis (2%)
- Trauma (<1%)
- Discogenic Dx
18
Q
Non-mechanical Causes of Low Back Pain
A
- Neoplasia (0.7%)
- Metastatic Carcinoma
- Multiple Myeloma
- Spinal Cord Tumor
- Lymphoma/Leukemia
- Infection (0.01%)
- Epidural Abscess
- Septic Discitis
- Inflammatory Dz (0.3%)
- Osteomyelitis
- Ankylosing Spondylitis
- Psoriatic Arthritis
- Reiter’s Syndrome
19
Q
Visceral Disease Causes of Low Back Pain
A
- Aortic Aneurysm
- Renal Dz
- Pelvic Dz
- Abdominal Dz
20
Q
Cause of Musculoligamentous Strain
A
Tear of the Muscle Fibers and/or Ligamentous Attachments of the Paraspinal Muscles
21
Q
Effects of Musculoligamentous Strain
A
Bleeding and Spasm, which causes local swelling and tenderness at the site
22
Q
Presentation of Musculoligamentous Strain
A
- A “specific” physical movement that caused injury. (Something gave way in my back)
- Onset of pain is usually immediate
- Pain radiated across the back, often to the buttock and upper thigh posteriorly
- Localized pain with minimal or no neurological findings and no ‘red flags.’
23
Q
Cause of Lumbar Disc Dz
A
- Pathphysio is not completely understood but it involves degenerative changes in the disc.
- Caused by a concentration of stress resulting from the forces associated with the upright position
- Injury, inflammation, weakening, and tearing of the disc annulus leads to pain
24
Q
Presentation of Lumbar Disc Disease
A
- Pain aggravated by bending
- Disc becomes weak and bulges beyond disc space
25
This is the term for focal or asymmetric extension beyond the interspace
Disc Protrusion
26
This is the term for extreme extension of the disc
Disc Extrusion
27
Effects of Disc Protrusion and Extrusion
Result in compression and irritation of the nerve roots.
28
What is the hallmark of nerve root irritation?
Sciatica
29
This is the term for the condition described by a sharp or burning pain which radiates down the posterior or lateral aspect of the leg to the ankle or foot. The pain may increase with Valsalva, coughing, sneezing, or lifting objects. Assc symptoms include: paresthesia, numbness, and weakness.
Sciatica
30
95%+ of protrusions of the spine occur where?
L4-L5, L5-S1
31
This condition predominantly occurs in the elderly with arthritis spurring, chronic disc degeneration, and facet joint arthritis, although it can occur in young people with congenital narrowed lumbar spinal canal. The narrowing of the spinal canal and formina leads to root impingement.
Spinal Stenosis
32
Presentation of Spinal Stenosis
- Pain is worse with standing, walking, or other activities that cause extension of the spine (Pseudoclaudication)
- Relieved by rest and flexion of the spine and hips
- Often bilateral pain
- May be accompanies by numbness or weakness
33
This is the condition defined by the forward subluxation of a vertebral body. In adults it is caused by the degenerative changes and arthritis of the facet joints (L4-L5 or L5-S1).
Spondylolisthesis
34
Cause of pain in Spondylolisthesis
Strain placed on ligaments and intervertebral bodies
35
T/F: Slippage usually is 10-20% of the vertebral body diameter.
True
36
This is the condition defined by the severe flexion-compression force on vertebra in normal bones. It is most commonly seen in the elderly with osteoporosis with long-term steroid use, cancer patients with boney metastases. It is commonly broughy on by minor stress.
Vertebral Compression Fx
37
Presentation of Vertebral Compression Fx
- Acutely painful with pain at the level of the fracture and radiation across the back and around the trunk
- Rarely in Lower Extremities
- More likely to occur in the middle or lower levels of the thoracic spine.
38
What is the most common spinal tumor?
Metastatic Carcinoma
| -- Breast, Lung, Prostate, Colon, Kidney
39
Most Common Primary Tumor
Myeloma
40
How do neoplasms cause pain?
- Involves periosteum and destroy bone
- Disc spaces usually spared and disc space height normal
- Collapse of vertebra makes it difficult to differentiate from vertebral compression fracture
41
T/F: Only 30% of people with metastatic tumors give a history of cancer.
True
42
Presentation of Neoplasm causing Low Back Pain
- Insidious onset with increasing severity
- Pain unrelieved or worsened by laying down or bed rest worsened with acitivity
- UMN signs
- Sensory loss in dermatomal distribution
- Autonomic Dysfunction may be seen
43
Possible Sources of Infection that could (rarely) lead to Low Back Pain
- UTI
- Skin Abscess
- Indwelling Catheters
- IVDA
44
This is the term for an infection that involved the disc space
Discitis
45
This is the term for an infection affecting the vertebrae usually due to hematogenous causes but may also come from a spinal procedure.
Vertebral Osteomyelitis
46
Presentation of Infection as Source of Low Back Pain
- Presents dull, achy, continuous pain
- Low grade fever (absent in ~50%)
- Tenderness to percussion over vertebra
47
Presentation of Epidural Abscess **Which could be from bacteremia or osteomyelitis
- Fever and Spinal Tenderness (~85%)
| - Can rapidly progress to major motor and sensory deficits in hours to days
48
This is the term for name for a family of inflammatory rheumatic diseases that cause arthritis. It usually has a strong assc with HLA-B27 positivity, suggesting immune pathology. RF is negative.
Sponyloarthropathy
49
What is the most common type of spondyloarthropathy?
Ankylosing Spondylitis
50
Presentation of Ankylosing Spondylitis
- Back Pain for at least 3 months
- Improvement with exercise, but not rest
- Limitation of lumbar spine motion and chest expansion
- Morning stiffness is typical
- Sacrolilitis on XR
51
What does sacrolilitis on a XR look like?
- Narrowing of SI Joint with reactive sclerosis
| - Bamboo Spine
52
Common causes of Low Back Pain that are Psychogenically related
1. Depression
| 2. Malingering
53
Presentation of Depression
- Chronic Low Back Pain
- Intensity of Symptoms and Degree of Disability are much greater than PE would suggest
- Multiple somatic complaints may be present
- Underlying somatization disorder may be present
54
Presentation of Malingering
- Inconsistencies in symptoms and PE findings
- Distract patient during PE
- Check Waddell Signs
55
This is a condition defined by a compromising of spinal canal below the L1 level.
Cauda Equina Syndrome
56
Most common cause of Cauda Equina Syndrome
Massive Midline Disk Herniation
57
Does Cauda Equina Syndrome require surgical urgency?
Nope, it's Emergent!
58
Presentation of Cauda Equina Syndrome
- Urinary Retention (90%)
- Saddle Anesthesia (~75%)
- Decreased Rectal Sphincter Tone
- Sciatica
- Lower Extremity Motor and Sensory Deficits (bilateral)
59
Red Flag Signs/Symptoms
- Pain related to another medical condition
- Minority of Patients
- Require more extensive work-up and probable referral
- Significant harm may result if dx is delayed
60
T/F: When a patient presents with back pain, you want to start examining the abdomen, rectum, groin, pelvis, and peripheral pulses before the back.
True
61
What are you looking for in a Physical Exam for Back Pain?
- Fever
- Skin Abscess
- Breast Mass
- Pleural Effusion
- Prostate Nodule
- Lymphadenopathy
- Joint Inflammation
- Thigh and Circumference for Evidence of Atrophy
- Joint Motion in LE
62
Observations during Physical Exam for Low Back Pain
- Gait can be observed as person walks to exam room
- Abnormal symmetry, muscle bulk, posture, spinal curvature
- Any obvious deformity?
- Any noted swelling?
- Any color changes?
- Any muscle atrophy?
- Scars?
63
T/F: Palpation of the back requires patient to be standing.
False, they could be sitting or standing
64
What muscle(s) are you using for flexion of the hip?
Iliopsoas
65
What muscle(s) are you using for extension of the hip?
Gluteus Maximus
66
What muscle(s) are you using for abduction of the hip?
- Gluteus Medius
| - Gluteus Minimus
67
What muscle(s) are you using for adduction of the hip?
- Adductor Brevis
- Adductor Longus
- Adductor Magnus
- Pectineus
- Gracilis
68
What muscle(s) are you using for external rotation of the hip?
- Internal Obturator
- External Obturator
- Quadratus Femoris
- Superior Gemelli
- Inferior Gemelli
69
What muscle(s) are you using for internal rotation of the hip?
- Gluteus Medius
| - Gluteus Minimus
70
This test is a sensitive indicator for lower lumbar disc herniation. It is performed by a person lying supine and the leg being passively lifted while knee is kept extended.
Straight Leg Raising
71
A positive Straight Leg Raising Test would be the reproduction of pain when the leg is elevated ___-___ degrees.
30-70 degrees
72
When an __ or __ nerve root is impinged upon by a herniated disc, it will cause ________ pain if stretched.
L5; S1; Radicular
73
T/F: When performing the Straight Leg Test, the earlier the onset of pain, the more specific the result and the greater the degree of herniation
True
74
These are non-organic signs used as a screen to help identify patients who need more detailed assessment.
Waddell Signs
75
This is a test that is defined by superficial and diffuse tenderness and/or non-anatomic tenderness.
Tenderness Test
76
This is a test that produces pain without actually causing movement, such as axial loading and pain on simulated rotation.
Simulation Test
77
This is a test that is checking for a positive result when the patient is distracted
Distraction Test
78
This is a test that denotes regional weakness or sensory changes which are inconsistent with neuroanatomy.
Regional Disturbances
79
What position is the patient in for the heel-tap test?
Seated
80
T/F: The majority of patients will have a diagnosis after an appropriate H&P.
True
81
T/F: Imaging is still warranted for most patients with acute Low Back Pain without signs and symptoms that indicate serious underlying conditions or direct trauma because of the potential damage to the spinal cord.
False, it is not warranted for most patients with acute Low Back Pain without signs and symptoms that indicate serious underlying conditions or direct trauma.
Studies show that imaging doesn't improve clinical outcomes in patients without underlying conditions.
82
Exceptions to no Imaging in patients without underlying conditions:
- Compensation Claims
| - Osteomyelitis
83
When should we consider imaging in a patient with low back pain without underlying conditions?
4 weeks of conservative tx and still in pain.
84
What is a good imaging study for someone with Low Back Pain and possible cancer metastases and/or osteomyelitis?
Radionuclide Scan
85
What is a good study for Infectious cause of Low Back Pain?
ESR
| Also would be positive if cancer or Multiple Myeloma
86
What is a good study for suspected Multiple Myeloma as the cause of Low Back Pain?
- Creatinine
- Calcium
- Immunoelectrophoresis
87
What is a good study for suspected Pyelonephritis as the cause of Low Back Pain?
Urinalysis
88
Symptomatic Management of Acute NonSpecific Back Pain
1. Pain resolves in 1/3 of patients by 1 week and 2/3 in 7 weeks
2. Initial relief with:
- - Heat or cold
- - Nonnarcotic analgesics—NSAIDs vs. acetaminophen (Preferred over narcotics)
- - Muscle relaxants: cyclobenzaprine (Flexeril)
- Lying supine with pillow tucked under knees and small pillow folded under the nape of the neck
3. Continue normal activity within limits permitted by pain
4. Twisting, bending, lifting should be avoided
5. PT, yoga, spinal manipulation, therapeutic message, acupuncture, “worthless measures” (spinal traction, facet-joint injection, transcutaneous nerve stimulation)
89
Symptomatic Management of Disc Herniation and Discogenic Pain
1. Conservative therapy initially as most patients improve significantly in 6 weeks (By week 6, only 10% need consideration for surgery)
2. Spinal manipulation should be avoided
3. Initial therapy consists of NSAIDs, avoidance of back stresses, and maintenance of activity
4. Opioid analgesic + muscle relaxant)
5. Epidural steroid injection in some select cases for short-term relief -- Little effect on long-term outcomes
6. Surgery for:
- - Persistent disabling nerve root pain despite 4-6 weeks of comprehensive conservative therapy or progressive neurological deficits in lower extremities
- - CT or MRI is indicated
90
Relapse and Primary Prevention of Low Back Pain
- Risk of Relapse = ~75%
- Exercise and Back Hygiene = Prevention
- Avoid activities that cause pain
- PT that improves muscle flexibility and strength
- Mild daily exercise with more vigorous exercise 2-3 times/week
91
Refractory Pain in Low Back Pain
Multiple mechanisms contribute to amplification of symptoms and refractoriness to therapy:
- Social Factors
- Underlying Psychopathology
- CNS Changes that inc. nerve excitability and hyperactivity
- No simple solutions and requires a comprehensive approach
92
Management of Psychopathology and Social Factors causing Low Back Pain
1. Depression: SSRIs
2. Suspected Somatization Disorder: Refer/ CBT
3. Pending Legal Matters: Settle Quickly
4. Reduce Pain
93
Management of Spinal Stenosis
1. Initial management can be conservative
2. PT: stretching, strengthening, aerobic exercises to improve strength, endurance, and flexibility
3. NSAIDs and other analgesics:
- -- Little inflammation associated with spinal stenosis—avoid NSAIDs
- -- Opioids
4. Epidural steroid injections are widely used but no RCTs
5. Surgery is “purely elective” and a reasonable consideration for people with incapacitating disease (debilitating pain, progressive neurologic impairment) -- Relapse rates are high
94
Indications for Admission
- Rapidly progressing neurologic deficits
- Symptoms suggestive of cauda equina syndrome
- Symptoms suggestive of cord compression
- New bilateral deficits
- Urinary retention
- Sphincter incontinence
- Saddle anesthesia
- UMN S/S
- Acute vertebral collapse
- Suspicion of osteomyelitis or epidural abscess
DDx
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