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Lower Back Pain . MS3 Sports Medicine Workshop. Objectives . Review the functional anatomy of lumbo-sacral spine List essential components of a LBP history, including RED FLAGS Describe common causes of LBP Review proper indications for imaging and referral

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Lower back pain l.jpg

Lower Back Pain

MS3 Sports Medicine Workshop


Objectives l.jpg
Objectives

  • Review the functional anatomy of lumbo-sacral spine

  • List essential components of a LBP history, including RED FLAGS

  • Describe common causes of LBP

  • Review proper indications for imaging and referral

  • Review Physical Examination of LS spine

  • Correlate pathology with pertinent physical findings


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“Red Flags” in back pain

  • Age < 15 or > 50

  • Fever, chills, UTI

  • Significant trauma

  • Unrelenting night pain; pain at rest

  • Progressive sensory deficit

  • Neurologic deficits

    • Saddle-area anesthesia

    • Urinary and/or fecal incontinence

    • Major motor weakness

  • Unexplained weight loss

  • Hx or suspicion of Cancer

  • Hx of Osteoporosis

  • Hx of IV drug use, steroid use, immunosuppression

  • Failure to improve after 6 weeks conservative tx


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Epidemiology of back pain

  • Fifth most common reason for all physician visits in US

  • Second only to common cold as cause of lost work time

  • 25% of US adults have LBP x1d in last 3 mos

  • The most common cause of disability in persons under the age of 45


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Your patient with LBP has paresthesias in the lateral foot, decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?

  • L4

  • L5

  • S1

  • S2


Better anatomy knowledge better diagnoses and treatments l.jpg
Better anatomy knowledge decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?=Better diagnoses and treatments


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  • Vertebra decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?

    • Body, anteriorly

      • Functions to support weight

    • Vertebral arch, posteriorly

      • Formed by two pedicles and two laminae

      • Functions to protect neural structures


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Ligaments decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?

  • Anterior longitudinal ligament

  • Posterior longitudinal ligament

  • Ligamentum flavum

  • Interspinous ligament

  • Supraspinous ligament


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Ligamentous decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?

Anterior longitudinal ligament


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Muscles decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?

  • Spinalis

  • Longissimus

  • Iliocostalis

  • Quadratus lumborum

    • Ilium to lumbar TPs

  • Intertransversalis

  • Interspinals

  • Multifidus

  • Erector spinae


Sciatica is defined as l.jpg
Sciatica is defined as… decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?

  • Pain radiating up the back

  • Pain radiating to the thigh

  • Pain radiating below the knee

  • Pain in the butt


Neuro anatomy l.jpg
Neuro-anatomy decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?


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  • L4 decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?

  • L5

  • S1


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PATIENT HISTORY decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?“OPQRSTU”

  • Onset

  • Palliative/Provocative factors

  • Quality

  • Radiation

  • Severity/Setting in which it occurs

  • Timing of pain during day

  • Understanding - how it affects the patient


Which one is not considered a red flag of lbp l.jpg
Which one is NOT considered a decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root? “red flag” of LBP?

  • History/suspicion of cancer

  • Age over 50

  • Fever or chills

  • Sciatica


Red flags in back pain22 l.jpg
“Red Flags decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?” in back pain

  • Age < 15 or > 50

  • Fever, chills, UTI

  • Significant trauma

  • Unrelenting night pain; pain at rest

  • Progressive sensory deficit

  • Neurologic deficits

    • Saddle-area anesthesia

    • Urinary and/or fecal incontinence

    • Major motor weakness

  • Unexplained weight loss

  • Hx or suspicion of Cancer

  • Hx of Osteoporosis

  • Hx of IV drug use, steroid use, immunosuppression

  • Failure to improve after 6 weeks conservative tx


Onset l.jpg
Onset decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?

  • Acute - Lift/twist, fall, MVA

  • Subacute - inactivity, occupational (sitting, driving, flying)

  • ?Pending litigation

  • Pain effect on:

    • work/occupation

    • sport/activity (during or after)

    • ADL’s


Other history l.jpg
Other History decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?

  • Prior h/o back pain

  • Prior treatments and response

  • Exercise habits

  • Occupation/recreational activities

  • Cough/valsalva exacerbation


Diagnoses red flags l.jpg

Cancer decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?

Age > 50

History of Cancer

Weight loss

Unrelenting night pain

Failure to improve

Infection

IVDU

Steroid use

Fever

Unrelenting night pain

Failure to improve

Fracture

Age >50

Trauma

Steroid use

Osteoporosis

Cauda Equina Syndrome

Saddle anesthesia

Bowel/bladder dysfunction

Loss of sphincter control

Major motor weakness

Diagnoses & Red Flags


Physical examination msk big 6 l.jpg
Physical Examination decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?Msk Big-6

  • Inspection

  • Palpation

  • Range of motion

  • Strength testing

  • Neurologic examination

  • Special tests


Approach to lbp l.jpg
Approach to LBP decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?

  • History & physical exam

  • Classify into 1 of 4:

    • BAD: LBP from other serious causes

      • Cancer, infection, caudaequina, fracture

    • LBP from radiculopathy or spinal stenosis

    • Non-specific LBP

    • Non-back LBP

  • Workup or treatment


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BAD low back pain (examples) decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?


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What to do about decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?Possible BAD Low Back Pain

  • Cauda Equina:

    • MRI STAT Neurosurgery consult

  • Fracture: x-rays

    • MRI/CT if still suspect

  • Cancer: x-rays + CRP, ESR, CBC (+/- PSA)

    • MRI if still suspect

  • Infection: x-rays; CRP, ESR, CBC, +/- UA


Radiculopathy spinal stenosis l.jpg
Radiculopathy, Spinal Stenosis decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?

  • Sciatica (pain below knee)

  • May have abnl neuro exam

  • Radiates to leg

  • Pain worse walking, better sitting (pseudo-claudication)


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What to do about decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?Suspected Radiculopathy or Spinal Stenosis

  • Refer to Physical Therapy

  • Follow in 2-4 weeks for progress

  • If no improvement by 6-12 weeks

    • Plain films, MRI, +/- EMG/NCV

    • Refer for interventions

      • Epidural steroid injections for radiculopathy


Causes of non specific lbp l.jpg

Spondylosis (Osteoarthritis of facet/disk) decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?

Spondylolysis/-listhesis

Kyphosis/scoliosis

Acute lumbar strain

Facet pain

Discogenic pain

Ligamentous pain

Causes of “Non-specific LBP”


Management of an acute low back muscle strain should consist of all the following except l.jpg
Management of an acute low back muscle strain should consist of all the following EXCEPT:

  • X-rays to rule out a fracture

  • Educate the patient on generally good prognosis

  • Non-opiate analgesics

  • Remain active


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What to do about of all the following EXCEPT:Non-specific Low Back Pain

  • Educate patient about expected good prognosis

  • Advise to remain active as tolerated

  • Provide analgesics and self-care directions

  • FU in 2-4 weeks; adjust tx as needed

  • Don’t do x-rays unless it becomes chronic

  • WU if no improvement


Think outside the back l.jpg

Renal dz (pyelo, stones, abscess) of all the following EXCEPT:

Pelvic dz (PID, endometriosis, prostate)

Gastrointestinal dz (cholecystitis, ulcer, cancer)

Retroperitoneal dz

Aortic aneurysm

Zoster

Diabetic radiculopathy

Rheumatologic disorders

Reiters

Ankylosing Spondylitis

Inflammatory bowel dz

Psoriatic spondylitis

Neoplasia (multiple myeloma, metastatic CA, lymphoma, leukemia, spinal cord tumors, vertebral tumors)

“Think Outside the Back”


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What to do about of all the following EXCEPT:Non-back LBP

  • WU and tx as appropriate for suspected diagnoses


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Diagnostic Studies of all the following EXCEPT:

Radiographs

Early if RED FLAGS

Symptoms present > 6 weeks despite tx


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Diagnostic Studies of all the following EXCEPT:

MRI indications

Possible cancer, infection, cauda equina synd

>6-12 weeks of pain

Pre-surgery or invasive therapy

Disadvantages

False-positives; may not be causing pain

More costly, increased time to scan, problem with claustrophobic patients


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Diagnostic Studies of all the following EXCEPT:

Bone Scan indications

Adolescent LBP (r/o spondy)

SPECT scan

Cost ~$300


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Diagnostic Studies of all the following EXCEPT:

EMG/NCV

r/o peripheral neuropathy

localize nerve injury

correlate with radiographic changes

order after 6-12 weeks of symptoms

Pre-surgical or invasive therapy


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Lab Studies of all the following EXCEPT:

Indications

Chronic LBP

Suspected systemic disease

CBC, CRP, ESR, +/- UA, SPEP, UPEP

Avoid RF, ANA or others unless indicated


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Issues specific to CHRONIC LBP of all the following EXCEPT:(>6 weeks and/or non-responsive)

  • Evaluation

    • X-rays, labs

    • Evaluate for “YELLOW FLAGS”

  • Management

    • Medication selection

    • Interventions


Yellow flags in chronic lbp l.jpg
YELLOW FLAGS of all the following EXCEPT:in Chronic LBP

  • Affect: anxiety, depression; feeling useless; irritability

  • Behavior: adverse coping, impaired sleep, treatment passivity, activity withdrawal

  • Social: h/o abuse, lack of support, older age

  • Work: believe pain will be worse at work; pending litigation; workers comp problems; poor job satisfaction; unsupportive work env’t


Medications in chronic lbp l.jpg
Medications in Chronic LBP of all the following EXCEPT:

  • FIRST: Acetaminophen

  • Second: NSAIDs

    • If one fails, change classes

      • Meloxicam  naproxen  COX2’s

  • Third: tramadol

  • Fourth: tri-cyclic antidepressants

    • Radiculopathy: gabapentin

  • LOATHE: narcotics


Non pharmacologic treatments l.jpg
Non-pharmacologic treatments of all the following EXCEPT:

EFFECTIVE

NOT EFFECTIVE/

CONFLICTING EVIDENCE

BACK SCHOOLS

LOW-LEVEL LASER

LUMBAR SUPPORTS

PROLOTHERAPY

SHORT WAVE DIATHERMY

TRACTION

ULTRASOUND

  • Acupuncture

  • Exercise therapy

  • Behavior therapy

  • Massage

  • TENS

  • Spinal manipulation

  • Multidisciplinary rehab program


Epidural steroid injections l.jpg
Epidural Steroid Injections of all the following EXCEPT:

  • Indicated for radiculopathy not responding to conservative mgmt

    • Conflicting evidence

    • Small improvement up to 3 months

    • Less effective in spinal stenosis


Surgery for chronic lbp l.jpg
Surgery for Chronic LBP of all the following EXCEPT:

  • Most do NOT benefit from surgery

  • Should have ANATOMIC LESION C/W PAIN DISTRIBUTION

  • Significant functional disability, unrelenting pain

    • Several months despite conservative tx

  • Procedures: spinal fusion, spinal decompression, nerve root decompression, disc arthroplasty, intradiscal electrothermal therapy


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Break for of all the following EXCEPT:Physical Examination Hands-on Session


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Inspection of all the following EXCEPT:

  • Observe for areas of erythema

    • Infection

    • Long-term use of heating element

  • Unusual skin markings

    • Café-au-lait spots

      • Neurofibromatosis

    • Hairy patches, lipomata

      • Tethered cord

    • Dimples, nevi (spina bifida)


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Inspection (cont.) of all the following EXCEPT:

  • Posture

    • Shoulders and pelvis should be level

    • Bony and soft-tissue structures should appear symmetrical

  • Normal lumbar lordosis

    • Exaggerated lumbar lordosis is common characteristic of weakened abdominal wall


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  • Posture of all the following EXCEPT:

    • Shoulders and pelvis should be level

    • Bony and soft-tissue structures should appear symmetrical

  • Normal lumbar lordosis

    • Exaggerated lumbar lordosis is common characteristic of weakened abdominal wall


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Bone Palpation of all the following EXCEPT:

  • Palpate L4/L5 junction (level of iliac crests)

  • Palpate spinous processes superiorly and inferiorly

    • S2 spinous process at level of posterior superior iliac spine

  • Absence of any sacral and/or lumbar processes suggests spina bifida

  • Visible or palpable step-off indicative of spondylolisthesis


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Soft Tissue Palpation of all the following EXCEPT:

  • 4 clinical zones

    • Midline raphe

    • Paraspinal muscles

    • Gluteal muscles

    • Sciatic area

    • Anterior abdominal wall and inguinal area


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ANTERIOR PALPATION of all the following EXCEPT:


Slide63 l.jpg

Flexion - 80º of all the following EXCEPT:

Extension - 35º

Side bending - 40º each side

Twisting - 3-18º

Range of Motion


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Neurologic Examinaion of all the following EXCEPT:

  • Includes an exam of entire lower extremity, as lumbar spine pathology is frequently manifested in extremity as altered reflexes, sensation and muscle strength

  • Describes the clinical relationship between various muscles, reflexes, and sensory areas in the lower extremity and their particular cord levels


Neurologic examination t12 l1 l2 l3 level l.jpg
Neurologic Examination of all the following EXCEPT:(T12, L1, L2, L3 level)

  • Motor

    • Iliopsoas - main flexor of hip

    • With pt in sitting position, raise thigh against resistance

  • Reflexes - none

  • Sensory

    • Anterior thigh


Neurologic examination l2 l3 l4 level l.jpg
Neurologic Examination of all the following EXCEPT:(L2, L3, L4 level)

  • Motor

    • Quadriceps - L2, L3, L4, Femoral Nerve

    • Hip adductor group - L2, L3, L4, Obturator N.

  • Reflexes

    • Patellar - supplied by L2, L3, and L4, although essentially an L4 reflex and is tested as such


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L2, L3, L4 testing of all the following EXCEPT:


Neurologic examination l4 level l.jpg
Neurologic Examination of all the following EXCEPT:(L4 level)

  • Motor

    • Tibialis Anterior

      • Resisted inversion of ankle

  • Reflexes

    • Patellar Reflex (L2, L3,L4)

  • Sensory

    • Medial side of leg


Neurologic examination l5 level l.jpg
Neurologic Examination of all the following EXCEPT:(L5 level)

  • Motor

    • Extensor Hallicus Longus

    • Resisted dorsiflexion of great toe

  • Reflexes - none

  • Sensory

    • Dorsum of foot in midline


Neurologic examination s1 level l.jpg
Neurologic Examination of all the following EXCEPT:(S1 level)

  • Motor

    • Peroneus Longus and Brevis

    • Resisted eversion of foot

  • Reflexes

    • Achilles

  • Sensory

    • Lateral side of foot


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Special Tests of all the following EXCEPT:

  • Tests to stretch spinal cord or sciatic nerve

  • Tests to increase intrathecal pressure

  • Tests to stress the sacroiliac joint


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Tests to Stretch the Spinal Cord or Sciatic Nerve of all the following EXCEPT:

  • Straight Leg Raise

  • Cross Leg SLR

  • Kernig Test


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Test to increase intrathecal pressure of all the following EXCEPT:

  • Valsalva Maneuver

    • Reproduction of pain suggestive of lesion pressing on thecal sac


Kernig sign l.jpg
Kernig of all the following EXCEPT: Sign

Pain relieved

Pain present


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Tests to stress the Sacroiliac Joint of all the following EXCEPT:

  • FABER Test

  • Gaenslen sign


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FABER of all the following EXCEPT: test:

Flexion

A-

Bduction

External

Rotation


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Gaenslen of all the following EXCEPT: sign


Non organic physical signs waddell s signs l.jpg
Non-organic Physical Signs of all the following EXCEPT:(“Waddell’s signs”)

  • Non-anatomic superficial tenderness

  • Non-anatomic weakness or sensory loss

  • Simulation tests with axial loading and en bloc rotation producing pain

  • Distraction test or flip test in which pt has no pain with full extension of knee while seated, but the supine SLR is markedly positive

  • Over-reaction verbally or exaggerated body language

Waddell, et al. Spine 5(2):117-125, 1980.


Hoover test l.jpg
Hoover Test of all the following EXCEPT:

  • Helps to determine whether pt is malingering

  • Should be performed in conjunction with SLR

  • When pt is genuinely attempting to raise leg, he exerts pressure on opposite calcaneus to gain leverage


Other l.jpg
Other of all the following EXCEPT:

  • Rectal tone

  • Anal wink

  • Cremasteric reflex


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Questions? of all the following EXCEPT:


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