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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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(OBQ11.119) A 35-year-old female presents for evaluation of new onset lumbar spine pain. Which of the following physical exam findings is indicative of an organic cause of low back pain symptoms? Review Topic

QID: 3542
1

Positive straight-leg raise with patient distraction

88%

(2728/3083)

2

Pain with axial loading of the spine

3%

(96/3083)

3

Diffuse tenderness with palpation of the paraspinal lumbar musculature

3%

(84/3083)

4

Lower extremity numbness in a non-dermatomal pattern

4%

(115/3083)

5

Pain with simulated rotation of the lumbar spine

2%

(52/3083)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ10.215) A 29-year-old male reports a 2-day history of atraumatic low back pain. He denies constitutional symptoms. He denies any bowel or bladder difficulties and physical examination reveals full motor strength and sensation. No pathologic reflexes are detected. All of the following are appropriate at the initial visit EXCEPT? Review Topic

QID: 3308
1

Limited oral analgesia

7%

(167/2460)

2

Radiographs of lumbar spine

84%

(2065/2460)

3

Schedule outpatient follow-up visit within 4 weeks

4%

(94/2460)

4

Early range of motion exercises

2%

(53/2460)

5

Reassurance

3%

(66/2460)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ07.116) A 32-year-old manual laborer has work-related chronic musculoskeletal back pain for several years. Which of the following is the strongest negative predictor for a successful clinical outcome with non-operative treatment? Review Topic

QID: 777
1

Race

0%

(6/2202)

2

Smoking status

20%

(450/2202)

3

High Visual Analog Scale (VAS) scores prior to treatment

41%

(913/2202)

4

Type of occupation

32%

(713/2202)

5

Gender

5%

(117/2202)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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GROUPS (1)
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