Epidural Abscess: Red Flag Findings
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Questions and Answers

What is the approximate percentage of the population affected by lumbosacral radiculopathy?

  • 9-10%
  • 6-8%
  • 3-5% (correct)
  • 1-2%

    • Which of the following is the single most common lumbar radiculopathy?

  • L5 radiculopathy (correct)
  • L3 radiculopathy
  • L4 radiculopathy
  • S1 radiculopathy

    • What is the most common symptom experienced by patients with lumbosacral radiculopathy?

  • Pain
  • Muscle weakness
  • Paresthesia (correct)
  • Numbness

    • Which of the following is a risk factor for lumbosacral radiculopathy?

    <p>Repetitive lifting and twisting motions</p> Signup and view all the answers

    What should be assessed during the history intake for lumbosacral radiculopathy?

    <p>All of the above</p> Signup and view all the answers

    What is typically worse with increased intradiscal pressure?

    <p>Pain</p> Signup and view all the answers

    What is an important associated sign or symptom to ask about during the history intake?

    <p>Saddle anesthesia</p> Signup and view all the answers

    What is the typical pain quality experienced by patients with lumbosacral radiculopathy?

    <p>All of the above</p> Signup and view all the answers

    What is the approximate incidence of cauda equina syndrome?

    <p>1:33,000-100,000</p> Signup and view all the answers

    What is the most common cause of cauda equina syndrome?

    <p>Lumbar disc herniation</p> Signup and view all the answers

    What is the diagnostic gold standard for cauda equina syndrome?

    <p>MRI</p> Signup and view all the answers

    What is the most common primary cancer that metastasizes to the spine?

    <p>Breast</p> Signup and view all the answers

    What is the typical presentation of vertebral fracture due to osteoporosis?

    <p>Chronic back pain with localized tenderness</p> Signup and view all the answers

    What is the recommended time frame for surgical decompression in cauda equina syndrome?

    <p>Within 24-48 hours</p> Signup and view all the answers

    What is the estimated number of new cases of cauda equina syndrome per year in the US?

    <p>1000</p> Signup and view all the answers

    Which of the following muscle weaknesses is associated with L2, L3, and L4 radiculopathy?

    <p>Knee extension</p> Signup and view all the answers

    Which of the following is a characteristic of L5 radiculopathy?

    <p>Pain radiating down the lateral leg into the foot</p> Signup and view all the answers

    Which of the following reflexes is absent in L2, L3, and L4 radiculopathy?

    <p>Patellar reflex</p> Signup and view all the answers

    Which of the following is a characteristic of chronic L5 radiculopathy?

    <p>Atrophy of the extensor digitorum brevis and tibialis anterior</p> Signup and view all the answers

    Which of the following motor weaknesses is associated with L5 radiculopathy?

    <p>Foot eversion and inversion</p> Signup and view all the answers

    What is the primary goal of counseling patients with radicular symptoms?

    <p>To reassure them of the low likelihood of serious pathology</p> Signup and view all the answers

    What is a key aspect of disease education for patients with radiculopathy?

    <p>Providing reassurance about the self-limited nature of the condition</p> Signup and view all the answers

    What is a common complication of acute radicular pain?

    <p>Loss of function and decreased quality of life</p> Signup and view all the answers

    What is the typical approach to pain management for patients with radiculopathy?

    <p>Combination of pharmacologic and nonpharmacologic options</p> Signup and view all the answers

    What is a red flag symptom that warrants an immediate emergent evaluation and potential surgical consultation?

    <p>Red Flag symptoms (e.g. Progressive neurologic deficit, infection, or cauda equina syndrome)</p> Signup and view all the answers

    What is the percentage of regression without treatment in Lumbar Disc Herniation, sequestration?

    <p>96%</p> Signup and view all the answers

    What is the recommended approach to physical activity for patients with radiculopathy?

    <p>Moderate level of physical activity</p> Signup and view all the answers

    What is the typical prognosis for most cases of lumbosacral radiculopathy?

    <p>Self-limited and resolving within 6-8 weeks</p> Signup and view all the answers

    Which of the following physical exam findings is associated with Lumbar Disc Herniation?

    <p>Weak ankle dorsiflexion</p> Signup and view all the answers

    What is the diagnostic accuracy of the Hancock Rule based on?

    <p>At least 3 of 4 findings in concordance with a specific nerve root</p> Signup and view all the answers

    What is an important aspect of patient education for those with radiculopathy?

    <p>Emphasizing the importance of weight loss reduction</p> Signup and view all the answers

    What is the sensitivity of the Straight Leg Raise (SLR) test in diagnosing Lumbar Disc Herniation?

    <p>73-98%</p> Signup and view all the answers

    What is the likely presentation of an acute injury in the distribution of L2, L3, and L4 radiculopathies?

    <p>Radiating back pain to the anterior aspect of the thigh</p> Signup and view all the answers

    What is the significance of calf wasting in Lumbar Disc Herniation?

    <p>It may take 4-6 weeks to develop and represents chronic impingement</p> Signup and view all the answers

    What is the likely distribution of pain in L2, L3, and L4 radiculopathies?

    <p>Radiating back pain to the anterior aspect of the thigh</p> Signup and view all the answers

    What is the likely cause of hematuria in a patient with a recent back trauma?

    <p>Renal injury</p> Signup and view all the answers

    What is the significance of early morning stiffness in a patient with low back pain?

    <p>It is associated with inflammatory arthritis</p> Signup and view all the answers

    What is the diagnosis of a patient with a history of malignancy and low back pain, who presents with urinary retention and incontinence?

    <p>Cauda equina syndrome</p> Signup and view all the answers

    What is the likely cause of muscular spasms in a patient with low back pain?

    <p>Spinal fracture</p> Signup and view all the answers

    What is the diagnostic test for lumbar disc herniation?

    <p>All of the above</p> Signup and view all the answers

    What is the significance of fever in a patient with low back pain?

    <p>It is a characteristic of discitis</p> Signup and view all the answers

    What is the likely presentation of a patient with L5 radiculopathy?

    <p>All of the above</p> Signup and view all the answers

    What is the key aspect of disease education for patients with radiculopathy?

    <p>Assessing ability to function in daily life</p> Signup and view all the answers

    What is the primary motor weakness associated with S1 radiculopathy?

    <p>Plantar flexion</p> Signup and view all the answers

    What is the most common symptom experienced by patients with lumbosacral radiculopathy, apart from pain?

    <p>Paresthesia</p> Signup and view all the answers

    Which of the following is a risk factor for lumbosacral radiculopathy?

    <p>All of the above</p> Signup and view all the answers

    What is the primary mechanism underlying spinal stenosis?

    <p>Degeneration of the vertebral bodies, joints and foramina due to 'wear and tear'</p> Signup and view all the answers

    In S1 radiculopathy, which of the following sensory changes is commonly seen?

    <p>Lateral foot and ankle, fourth and fifth toes</p> Signup and view all the answers

    What is the estimated prevalence of spinal stenosis in individuals aged 60-69 years?

    <p>19.4%</p> Signup and view all the answers

    Which of the following reflexes is typically absent in S1 radiculopathy?

    <p>Ankle reflex</p> Signup and view all the answers

    What is the likely course of pain in patients with lumbosacral radiculopathy?

    <p>Pain worsens with forward flexion of the lumbar spine</p> Signup and view all the answers

    What is the term used to describe the slippage of one vertebral body with respect to the adjacent vertebral body?

    <p>Spondylolisthesis</p> Signup and view all the answers

    What is the term used to describe a weakness or stress fracture through the pars interarticularis?

    <p>Spondylolysis</p> Signup and view all the answers

    During the history intake, what is an important aspect to assess?

    <p>All of the above</p> Signup and view all the answers

    What is the distribution of pain in S1 radiculopathy?

    <p>Sacral or buttock pain into the posterior aspect of the leg, into the foot, or the perineum</p> Signup and view all the answers

    What is the significance of checking for absent ankle reflexes in patients with lumbosacral radiculopathy?

    <p>It is a sign of nerve root compression</p> Signup and view all the answers

    What is the term used to describe age-related degeneration of the spinal column?

    <p>Spondylosis</p> Signup and view all the answers

    What is the typical approach to managing pain in patients with lumbosacral radiculopathy?

    <p>Conservative management with physical therapy and pain medication</p> Signup and view all the answers

    What is the presentation of spinal stenosis in terms of symptoms?

    <p>Back pain with numbness or loss of strength in the lower extremities</p> Signup and view all the answers

    What is the significance of asking about saddle anesthesia in patients with lumbosacral radiculopathy?

    <p>It is a sign of cauda equina syndrome</p> Signup and view all the answers

    What is the primary reason for the relief of pain in neurogenic claudication?

    <p>Lumbar flexion</p> Signup and view all the answers

    What is the percentage of patients who are asymptomatic in spondylolysis?

    <p>90%</p> Signup and view all the answers

    What is the typical presentation of patients with spinal stenosis?

    <p>Pain exacerbated with lumbar hyperextension</p> Signup and view all the answers

    What is the risk factor associated with spondylolysis?

    <p>All of the above</p> Signup and view all the answers

    What is the prediction rule for diagnosing spinal stenosis?

    <p>Score ≥ 7</p> Signup and view all the answers

    What is the percentage of patients who eventually undergo repeat surgery for spinal stenosis?

    <p>19%</p> Signup and view all the answers

    What is the primary causative organism of vertebral osteomyelitis?

    <p>Staphylococcus aureus</p> Signup and view all the answers

    Which of the following is a common risk factor for vertebral infection?

    <p>Recent spinal procedure/surgery</p> Signup and view all the answers

    What is the preferred diagnostic imaging modality for vertebral osteomyelitis?

    <p>MRI</p> Signup and view all the answers

    What is the approximate percentage of cases of osteomyelitis that affect the spine?

    <p>3-5%</p> Signup and view all the answers

    Which of the following is a common symptom of vertebral infection?

    <p>Fever</p> Signup and view all the answers

    What is the most common site of vertebral infection?

    <p>Lumbar spine</p> Signup and view all the answers

    Which of the following occupations is more likely to develop lumbosacral radiculopathy due to repetitive lifting and twisting motions?

    <p>Driver</p> Signup and view all the answers

    What is the typical course of pain in lumbosacral radiculopathy?

    <p>Slowly increasing pain with radiation into the lower limb</p> Signup and view all the answers

    What is the primary goal of assessing dermatomal distribution during the history intake?

    <p>To identify the affected nerve root</p> Signup and view all the answers

    Which of the following is not a characteristic of pain experience in lumbosacral radiculopathy?

    <p>Dull ache</p> Signup and view all the answers

    What is the significance of saddle anesthesia in lumbosacral radiculopathy?

    <p>Suggests cauda equina syndrome</p> Signup and view all the answers

    Which of the following is a common risk factor for lumbosacral radiculopathy?

    <p>Sedentary lifestyle</p> Signup and view all the answers

    What is the typical pattern of pain radiation in S1 radiculopathy?

    <p>Posterior aspect of the leg into the foot, or perineum</p> Signup and view all the answers

    Which of the following physical exam findings is associated with S1 radiculopathy?

    <p>Ipsilateral calf wasting</p> Signup and view all the answers

    What is the typical sensory change seen in S1 radiculopathy?

    <p>Paresthesia in the lateral foot and ankle</p> Signup and view all the answers

    Which of the following reflexes is typically absent in S1 radiculopathy?

    <p>Ankle reflex</p> Signup and view all the answers

    What is the primary mechanism underlying neurogenic claudication in spinal stenosis?

    <p>Lumbar extension induced compression of spinal nerve roots</p> Signup and view all the answers

    What is the primary risk factor associated with spondylolysis?

    <p>Excessive lumbar lordosis</p> Signup and view all the answers

    What is the typical presentation of spondylolysis?

    <p>Insidious onset, recurrent axial low back pain exacerbated by activity</p> Signup and view all the answers

    What is the diagnostic gold standard for spinal stenosis?

    <p>Imaging</p> Signup and view all the answers

    What is the approximate percentage of patients with spondylolysis who are asymptomatic?

    <p>90%</p> Signup and view all the answers

    What is the likelihood of lumbar spinal stenosis in patients with a score ≥ 7 on the prediction rule?

    <p>High likelihood</p> Signup and view all the answers

    What is the significance of a wide-based gait in patients with spinal stenosis?

    <p>Is a non-specific finding</p> Signup and view all the answers

    What percentage of bilateral spondylolysis will have spondylolisthesis at diagnosis?

    <p>50-75%</p> Signup and view all the answers

    What is the most common cause of spondylolisthesis?

    <p>Degenerative</p> Signup and view all the answers

    What is the typical presentation of spondylolisthesis in adults?

    <p>Intermittent and localized low back pain radiating into the buttock or posterior thigh</p> Signup and view all the answers

    What is the recommended initial imaging modality for spondylolisthesis?

    <p>MRI</p> Signup and view all the answers

    What is the purpose of Meyerding's Classification in spondylolisthesis?

    <p>To grade the severity of spondylolisthesis</p> Signup and view all the answers

    What is the typical grade of spondylolisthesis in older patients?

    <p>Grade I</p> Signup and view all the answers

    What is the indication for imaging in patients with low back pain?

    <p>Patients with severe symptom intensity or red flag findings</p> Signup and view all the answers

    What is a common feature of spondylolisthesis on X-ray?

    <p>Pars fracture</p> Signup and view all the answers

    Study Notes

    Here are the study notes for the text:

    Red Flag Findings for Epidural Abscess

    • Fecal incontinence or loss of bowel control
    • Urinary retention or loss of bladder control
    • Saddle anesthesia
    • Unexplained fever
    • Unexplained weight loss
    • Focal neurological deficit, progressive or disabling symptoms
    • No improvement after 6 weeks of conservative management
    • Immunosuppression, recent infection, chronic steroid use, osteoporosis, significant trauma, or history of cancer

    Diagnostic Accuracy of Individual Red Flag Findings

    • Age > 50 years: sensitivity 74%, LR+ 1.1, LR- 0.79
    • Recent loss of bladder control: sensitivity 22.2%, LR+ 2.31, LR- 0.86
    • Recent loss of bowel control: sensitivity 13.9%, LR+ 2.78, LR- 0.91
    • Unexplained weight loss: sensitivity 8.2%, LR+ 1.87, LR- 0.96
    • Personal history of cancer: sensitivity 32%, LR+ 7.25, LR- 0.71
    • Fever, chills, or sweating: sensitivity 11.7%, LR+ 1.71, LR- 0.95
    • Recent infection: sensitivity 24.2%, LR+ 9.31, LR- 0.78

    Diagnostic Accuracy of Combined Red Flag Findings

    • Trauma + Age > 50 years: sensitivity 14.8%, LR+ 2.54, LR- 0.90
    • Trauma + Age > 70 years: sensitivity 5.2%, LR+ 4.35, LR- 0.96
    • Recent loss of bowel + bladder control: sensitivity 8.3%, LR+ 3.0, LR- 0.94
    • Unexplained weight loss + personal history of cancer: sensitivity 2.5%, LR+ 10.25, LR- 0.98
    • Fever, chills, or sweating + recent infection: sensitivity 7.5%, LR+ 13.15, LR- 0.93

    Cauda Equina Syndrome

    • Compression and disruption of function to cauda equina (L3-L5 nerve roots)
    • Classical symptoms: new urinary retention or overflow incontinence, fecal incontinence, progressive motor or sensory loss, saddle anesthesia, lower motor neuron weakness, and significant deficits that encompass multiple nerve roots
    • Diagnosis: imaging (MRI) is diagnostic gold standard
    • Urgent ER referral; requires surgical decompression within 24-48 hours

    Spinal Malignancy: Metastases

    • Most common tumors of the spine are metastases of other primary cancers (breast, lung, prostate, renal, gastrointestinal, and thyroid)
    • Personal history of cancer, back pain, unexplained weight loss, possibly sensory loss, weakness, or radiculopathy
    • Diagnosis: imaging (x-ray or MRI) and blood work (incl CBC) and symptoms depend on type of primary cancer
    • Urgent referral back to oncologist or palliative care

    Vertebral Fracture

    • A break in one or more spinal vertebrae that can result from trauma and metastatic disease but, in most cases, are the result of osteoporosis (at T11-L2)
    • Low bone density, female > 50 years, prolonged use of corticosteroids, trauma/fall, personal history of vertebral fracture
    • Back pain (acute or chronic, localized)

    LBP with Radiculopathy: Epidemiology

    • Lumbosacral radiculopathy is common: 3-5% of population
    • Male > 40 years, female > 50 years, 3:2
    • L5 radiculopathy is the single most common lumbar radiculopathy

    LBP with Radiculopathy: Risk Factors

    • Social history: repetitive lifting and twisting motions, chronic overloading of disc, driving occupations, heavy industry work, military, smoking, overweight, sedentary
    • Medical history: prior trauma, multiple pregnancies, history of back pain, chronic cough

    LBP with Radiculopathy: History Intake

    • Site: ask about the location of the back pain
    • Onset: how and when the back pain developed
    • Quality: pain is often described as throbbing, aching, sharp, dull, burning, pressure, numbness, tingling, or shooting
    • Radiation: assess dermatomal distribution
    • Time course: consider how the back pain changed over time
    • Severity of pain experience: scale of 1-10
    • Pain is typically worse with: increased intradiscal pressure, Valsalva, weight bearing, standing, walking, sitting for prolonged periods
    • Pain is typically better with: extension of the lumbar spine, recumbent position (knees flexed)
    • Associated signs and symptoms: motor or sensory disturbances, suggestive of nerve root or spinal cord compression

    Physical Exam Findings associated with Lumbar Disc Herniation

    • Weak ankle dorsiflexion: sensitivity 54%, LR+ 4.9, LR- 0.5
    • Calf wasting: sensitivity 29%, LR+ 5.2, LR- 0.8
    • Leg sensation abnormal: sensitivity 16%, LR+ NS, LR- NS
    • Abnormal ankle reflex: sensitivity 48%, LR+ 4.3, LR- 0.6
      • Straight Leg Raise (SLR) test: sensitivity 73-98%, LR+ NS, LR- 0.2
      • Crossed SLR test: sensitivity 23-43%, LR+ 4.3, LR- 0.8

    Hancock Rule: Clinical Prediction Rule for Lumbar Disc Herniation

    • The diagnostic accuracy of multiple neurologic findings improves clinician ability to determine level of disc herniation if at least 3 of 4 findings are in concordance with a specific nerve root:
      • dermatomal pain location
      • sensory deficit
      • reduced reflex
      • motor weakness
    • Findings: score ≥ 3 for L3/L4 disc herniation, sensitivity 50%, LR+ 5.0, LR- 0.56
    • Findings: score ≥ 3 for L4/L5 disc herniation, sensitivity 37%, LR+ 2.18, LR- 0.76
    • Findings: score ≥ 3 for L5/S1 disc herniation, sensitivity 28%, LR+ 4.67, LR- 0.77

    LBP with Radiculopathy: Epidemiology

    • 3-5% of population has lumbosacral radiculopathy, with males (40+ years) more common than females (50+ years) at a 3:2 ratio
    • L5 radiculopathy is the single most common lumbar radiculopathy
    • Pain experience: often described as tingling, electric, burning, or sharp
    • Paresthesia: 63-72% of patients, radiation of pain into lower limb: 35%, numbness (anesthesia): 27%, and muscle weakness: up to 37%

    LBP with Radiculopathy: Risk Factors

    • Social History:
      • Repetitive lifting and twisting motions
      • Chronic overloading of disc: driving occupations, heavy industry work, military
      • Lifestyle: smoking, overweight, sedentary
    • Medical History:
      • Prior trauma (fall, motor vehicle accident)
      • Multiple pregnancies
      • History of back pain
      • Chronic cough

    LBP with Radiculopathy: History Intake

    • Site: ask about the location of the back pain
    • Onset: how and when the back pain developed
    • Quality: pain is often described as throbbing, aching, sharp, dull, burning, pressure, numbness, tingling, or shooting
    • Radiation: assess dermatomal distribution
    • Time Course: consider how the back pain changed over time

    LBP with Radiculopathy: Associated Signs and Symptoms

    • Motor or sensory disturbances: suggestive of nerve root or spinal cord compression
    • Ask specifically about saddle anesthesia if cauda equina syndrome is a possibility
    • Urinary retention or incontinence: typical features of cauda equina syndrome
    • Hematuria (blood in urine): may occur secondary to back trauma

    LBP with Radiculopathy: History Intake

    • Associated Signs and Symptoms:
      • Fever: typically associated with urinary tract infection, pneumonia, and discitis
      • Malaise: associated with a wide range of pathology but in the context of back pain, consider discitis or malignancy
      • Weight loss: associated with malignancy
      • Early morning stiffness: associated with inflammatory arthritis (e.g., rheumatoid arthritis, ankylosing spondylitis)
      • Muscular spasms: may be associated with spinal fracture or primary muscular injury

    LBP with Radiculopathy: Key Medical History

    • History of malignancy
    • Recent bacterial infections
    • Recent history of epidural or spinal surgical procedures
    • Medications: history of or current corticosteroid use
    • Assess ability to function in daily life

    Disc Herniation

    • Displacement of intervertebral disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space
    • 1-3% of patients with acute LBP; age 30-40, male: female 2:1
    • Acute-chronic pain, paresthesia, sensory change, loss of strength or reflexes (depends on affected nerve root)
    • Diagnosis: SLR + Hancock rule

    S1 Radiculopathy

    • Distribution of Pain:
      • S1 radiculopathy will cause radiation of sacral or buttock pain into the posterior aspect of the patient's leg, into the foot, or the perineum
    • Physical Exam:
      • Motor Weakness: plantar flexion
      • Paresthesia/Sensory Changes: sole, lateral foot and ankle, fourth and fifth toes
      • Absent Reflexes: ankle reflex (S1)

    S1 Radiculopathy: Physical Exam Findings

    • Weak ankle plantar flexion: 26-45% sensitivity
    • Ipsilateral calf wasting: 43% sensitivity
    • Sensory loss in S1 distribution: 32-49% sensitivity
    • Asymmetric achilles reflex: 45-91% sensitivity

    Serious Disorders Affecting the Lumbar Spine

    • Spondylosis: an umbrella term for age-related degeneration of the spinal column (often involves degenerative disc disease and facet arthropathy)
    • Spinal stenosis: narrowing of the spinal canal, neural foramen, and lateral recess which can lead to compression of the nerve roots and neurogenic claudication
    • Spondylolysis: weakness or stress fracture through the pars interarticularis
    • Spondylolisthesis: the slippage of one vertebral body with respect to the adjacent vertebral body

    Spinal Stenosis

    • Narrowing of the spinal canal, neural foramen, and lateral recess which can lead to compression of the nerve roots and neurogenic claudication
    • 3% with mechanical low back pain (LBP), 19.4% aged 60-69 years
    • LBP with B/L lower extremity pain, numbness or loss of strength (depends on affected nerve root) aggravated by ambulation, standing, and lumbar extension
    • Neurogenic claudication: pain/discomfort with walking or prolonged standing that radiates into one or both lower extremities (relieved by rest/sitting, lumbar flexion)
    • Diagnosis: imaging is diagnostic

    Vertebral Infection: Osteomyelitis

    • Most common vertebral infection, particularly the vertebral body
    • Often caused by hematogenous spread of Staphylococcus aureus
    • Rare, approx. 4.8 cases per 100,000 in US, 3-5% of all cases of osteomyelitis
    • Risk factors: recent spinal procedure/surgery, recent infection, wound in spinal region, Hx IV drug use, immunosuppression
    • Symptoms: back pain, fever, sensory loss, weakness or radiculopathy
    • Diagnosis: imaging (MRI) is preferred, CBC often normal, ESR elevated, CRP elevated, blood cultures
    • Urgent ER referral, requires antibiotic therapy (IV and oral)

    LBP with Radiculopathy: Etiology

    • L4-L5 (L5 nerve root) and L5-S1 (S1 nerve root) are most susceptible to injury
    • Particularly flexible part of lumbar spine, bears more impact than thoracic and cervical spine

    LBP with Radiculopathy: Epidemiology

    • Lumbosacral radiculopathy is common: 3 - 5% of population
    • Male (40yr+) > female (50yr+): 3:2
    • L5 radiculopathy is the single most common lumbar radiculopathy

    LBP with Radiculopathy: Risk Factors

    • Social History: repetitive lifting and twisting motions, chronic overloading of disc, smoking, overweight, sedentary
    • Medical History: prior trauma, multiple pregnancies, history of back pain, chronic cough

    LBP with Radiculopathy: History Intake

    • Site: ask about the location of the back pain
    • Onset: how and when the back pain developed
    • Quality: pain is often described as throbbing, aching, sharp, dull, burning, pressure, numbness, tingling, or shooting
    • Radiation: assess dermatomal distribution
    • Time Course: consider how the back pain changed over time
    • Pain experience: scale of 1-10, pain is typically worse with increased intradiscal pressure, pressure increases with coughing, sneezing, straining, forward flexion of the lumbar spine

    LBP with Radiculopathy: Physical Exam

    • Motor Weakness: plantar flexion
    • Paresthesia/Sensory Changes: sole, lateral foot and ankle, fourth and fifth toes
    • Absent Reflexes: ankle reflex (S1)

    Spinal Stenosis

    • Pain/discomfort with walking or prolonged standing that radiates into one or both lower extremities (relieved by rest/sitting, lumbar flexion)
    • Diagnosis: imaging is diagnostic
    • Subjective + Physical Findings associated with Spinal Stenosis:
      • No pain when seated
      • Unexplained urinary disturbance
      • Symptoms improve with bend forward
      • Bilateral buttock or leg pain
      • Neurogenic claudication
      • Wide-based gait
      • Abnormal rhomberg test

    Spondylolysis

    • Unilateral or bilateral defect through the pars interarticularis (most commonly affects L5, 90%)
    • 6-18% population (14+); up to 50% young athletes (male:female, 2:1)
    • Risk associated with excessive lumbar lordosis, genetics (fHx)
    • Asymptomatic (90% of patients); insidious onset, recurrent axial low back pain exacerbated with activity or lumbar hyperextension, +/- radiculopathy

    Spondylolisthesis

    • Slippage of one vertebral body with respect to the adjacent vertebral body
    • 3-4% of patients with mechanical LBP
    • Adults, female > male, obesity, fHx (spondylolisthesis, scoliosis, spina bifida)
    • Intermittent and localized low back pain that radiates into buttock or posterior thigh; paresthesia, sensory change, loss of strength or reflexes (depends on affected nerve root)

    Evaluation - Imaging

    • Initial imaging is not indicated in the majority of patients with low back pain
    • Conservative management for 6 weeks is typically recommended before considering imaging (radiography, MRI, CT)
    • UNLESS presenting with severe symptom intensity or red flag findings for conditions that require timely diagnosis to prevent serious consequences

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