Low Back Pain question well done 2023/2024.

Low Back Pain Prevalence - answersLow back pain (LBP) is the fifth most common reason for all doctor visits. In the U.S., lifetime prevalence of LBP is 60% to 80%. The direct and indirect costs for treatment of LBP are estimated to be $100 billion annually. Fortunately, most LBP resolves in two to four weeks. Common causes of Back Pain - answersMSK causes: -Degenerative disc disease -Facet arthritis -Sacroiliitis -Ankylosing spondylitis -Discitis -Paraspinal muscular issues -SI dysfunction -Disc prolapse -Spinal stenosis Trauma: -Lumbar Strain -Compression fracture Neoplastic: -Lymphoma/leukemia -Metastatic disease -Multiple myeloma -Osteosarcoma Inflammatory: -Rheumatoid Arthritis Visceral: -Endometriosis -Prostatitis -Renal Litiasis Lower back pain differential - answersInfection: -Discitis -Herpes zoster -Osteomyelitis -Pyelonephritis -Spinal or epidural abscess Vascular: -Aortic aneurysm Endocrine: -Hyperparathyroidism -Osteomalacia -Osteoporosis -Paget disease Three most common causes of back pain - answers1. lumbar strain/sprain - 70% 2. age-related degenerative joint changes in the disks and facets - 10%. 3. herniated disc - 4% other less common causes of mechanical low back pain are osteoporotic fracture and spinal stenosis Acute sciatica - answersAcute sciatica is lower back pain with radiculopathy below the knee and symptoms lasting up to six weeks. Sciatica is a common and costly problem, caused by a variety of conditions: disk herniation, lumbar spinal stenosis, facet joint osteoarthritis or other arthropathies, spinal cord infection or tumor, or spondylolisthesis. Red flags for serious illness or neurologic impairment with back pain - answers-Fever -Unexplained weight loss -Pain at night -Bowel or bladder incontinence -Neurologic symptoms -Saddle anesthesia Cauda equina syndrome - answersShould always be considered due to the seriousness of the consequences. Occurs when a large mass effect (such as an acute disc herniation or a tumor) compresses the cauda equina, causing pain radiating down the leg and can be accompanied by weakness and numbness of the leg. True emergency. Decompression should be performed within 72 hours to avoid permanent neurologic deficits. Low on the differential if the patient denies problem with bowel or bladder control. Malignancy - answersImportant consideration. A very serious, although uncommon, cause of back pain. Unlikely without a history of cancer. Back pain due to malignancy is localized to the affected bones, it is a dull, throbbing pain that progresses slowly, and it increases with recumbency or cough. More commonly seen in patients over 50. Ankylosing spondylitis - answersChronic, painful, inflammatory arthritis primarily affecting the spine and sacroiliac joints, causing eventual fusion of the spine. Often seen in patients 15-40 years old, associated with morning stiffness and achiness over the sacroiliac joint and lumbar spine. Spondylolistheisis - answersAnterior displacement of a vertebra or the vertebral column in relation to the vertebrae below. Can occur at any age. Causes aching back and posterior thigh discomfort that increases with activity or bending. Prostatitis - answersCan cause referred LBP in men. (Pelvic inflammatory disease and endometriosis in women can cause referred LBP). Expect to find evidence of infection in the history. Physical exam for Back pain in the standing position - answers1) inspection: -look at posure, contour, and symmetry 2) palpation: -check for any tenderness, tightness, rope-like tension, or inflammation in the paraspinous muscles or tenderness over bony prominences. This procedure checks for muscle spasm, vertebral fracture, or infection. 3) range of motion - Lumbar Flexion (normal is 90 degrees): This is the best measure of spine mobility. Restriction and pain during flexion are suggestive of herniation, osteoarthritis, or muscle spasm. -Lumbar Extension (normal is 15 degrees): Pain with extension is suggestive of degenerative disease or spinal stenosis. -Lateral motion (normal is 45 degrees): Most patients should be able to touch the proximal fibular head of the knee. Pain on the same side as bending is suggestive of bone pathology, such as osteoarthritis or neural compression. Pain on the opposite side of bending is suggestive of a muscle strain. Range of motion may be varied due to the patient's age and body habitus More physical exam in the standing position - answers4) Gait: Ask the patient to walk on heels and toes. Expect normal gait, even with disc herniation. -Difficulty with heel walk is associated with L5 disc herniation -Difficulty with toe walk is associated with S1 disc herniation 5) Stoop Test: Have the patient go from a standing to squatting position. In patients with central spinal stenosis, squatting will reduce the pain. However, asking the patient to run is not part of a back exam and may cause discomfort to the patient who is already in pain. Seated back exam - answersAsses -CVA tenderness (suggestive of pyelonephritis) -positioning -reflexes and strength in the lower extremity Focus on the L4, L5, and S1 nerve roots because most neuropathic back pain is due to impingement of these. Therefore, check the patellar reflex (L2-4) and Achilles reflex (S1). Check muscle strength for hip flexion, abduction, and adduction; knee extension and flexion; as well as ankle dorsiflexion and plantar flexion. Also, test for sharp and light touch along the dermatomal distribution of the great toe (L5), lateral malleolus and posterolateral foot (S1). Supine Exam - answersAbdominal Exam: -Auscultation: Check for abdominal bruit, looking for abdominal aortic aneurysm. -Palpation: Check for abdominal tenderness (on all patients, not just female patients), pelvic tenderness (PID), pulsatile mass, unequal femoral/brachial pulses (abdominal aortic aneurysm), or any general tenderness indicating visceral pathology. Rectal Exam: -To be done only on patients with red flags or alarm symptoms, which we will discuss later! -Check for masses, bleeding, or abnormal rectal tone. Bleeding or rectal mass can be signs of cancer with metastasis to the spine causing back pain. Decreased tone can indicate disc herniation and/or cauda equina syndrome. Passive straight leg raise - answers(SLR or Lasegue's sign) The normal leg can be raised 80 degrees. If a patient only raises their leg <80 degrees, they have tight hamstrings or a sciatic nerve problem. To differentiate between tight hamstrings and a sciatic nerve problem, raise the leg to the point of pain, lower slightly, then dorsiflex the foot. If there is no pain with dorsiflexion, the patient's hamstrings are tight. The test is positive if pain radiates down the posterior/lateral thigh past the knee. This radiation indicates stretching of the nerve roots (specifically S1 or L5) over a herniated disc. This pain will most likely occur between 40 and 70 degrees. Pain earlier than 30 degrees is suggestive of malingering.