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Introduction
  • Low back pain affects 50-80% of population in lifetime
    • $100 billion in annual cost 
    • second only to respiratory infection as cause to visit doctors office
  • Etiology
    • muscle strain
      • most common cause of low back pain
    • most common degenerative disorders
      • lumbar spinal stenosis
      • lumbar disc herniation
      • discogenic back pain
  • Risk factors 
    • obesity, smoking, gender
    • lifting, vibration, prolonged sitting
    • job dissatisfaction
  • Red flags
    • infection (IV drug user, h/o of fever and chills)
    • tumor (h/o or cancer)
    • trauma (h/o car accident or fall)
    • cauda equina syndrome (bowel/bladder changes)
  • Outcomes
    • 90% of low back pain resolves within one year
Presentation
  • Symptoms
    • axial pain
      • musculogenic
        • most common cause of back pain
        • associated with activity
        • characterized by stiffness and difficulty bending
      • discogenic pain
        • controversial
        • confirmed by discogram
      • mechanical pain
        • caused by 
          • facet degeneration
          • micro and macro instability
        • worse with activity such as lifting objects and prolonged standing
      • sacroiliac symptoms
        • pain originating from sacroiliac joint
    • peripheral / neurogenic
      • radicular pain
        • unilateral leg pain
        • usually dermatomal
      • referred pain
        • buttocks
        • posterior thighs
        • inguinal region (think L5-S1)
      • neurogenic claudication
        • pain in buttock and legs that is worse with prolonged standing
        • fairly specific for spinal stenosis
      • myelopathy
        • clumsiness in hands
        • gait instability
        • due to injury of spinal cord (~ L1 or above)
      • conus medullaris syndrome
      • cauda equina syndrome
        • bilateral leg pain
        • LE weakness
        • saddle anesthesia
        • bowel/bladder symptoms
      • spinal cord injury
        • incomplete
        • complete
  • Wadell Signs 
    • system to evaluate non-organic back pain symptoms, 
    • clinically significant if three positive signs are present
      • superficial and non-anatomic tenderness
      • pain with axial compression or simulated rotation of the spine
      • negative straight-leg raise with patient distraction
      • regional disturbances which do not follow dermatomal pattern
      • overreaction to physical examination
Imaging
  • Radiographs  
    • indications for radiographs
      • pain lasting > one month and not responding to not nonoperative management
      • red flags are present
  • MRI
    • highly sensitive and specific  
    • high rate of abnormal findings on MRI in normal people
 
Positive MRI Findings in Asymptomatic Patients
Age % HNP
% Disc Bulge % Degeneration
20-39 21
56 34
40-59 22 50 59
60-79 36 79 93
 
Differential 
  • Neck and arm pain
    • trauma
    • cervical spondylosis
    • metastatic disease / infection
    • cervical radiculopathy
    • cervical myelopathy
    • ankylosing spondylitis
  • Thoracic back and rib pain
    • trauma
    • metastatic disease / infection
    • thoracic disc herniation
    • osteoporotic comression fracture
    • trauma 
  • Low back pain
    • muscles strain
    • disc herniation / discogenic pain
    • degenerative spondylolithesis
    • spinal stenosis
    • lumbar radiculopathy
    • abdominal aortic aneurism
  • Sacroiliac pain
    • SI infection
    • ankylosing spondylitis
  • Sacral pain
    • coccydynia
    • sacral insufficiency fracture
Treatment
  • Treatment dictated by cause of pain.
 

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