Low back pain
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Questions and Answers

What is the most common systemic disease affecting the spine?

  • Osteoporosis
  • Cancer (correct)
  • Infection
  • Arthritis

    • A patient presents with back pain and has a history of cancer. What should the practitioner consider?

  • Cancer until proven otherwise (correct)
  • Infection or inflammation
  • Musculoskeletal imbalance
  • Other possible causes of back pain

    • What is the likelihood that a patient with a malignant spinal neoplasm is over 50 years old?

  • 90%
  • 70%
  • 80% (correct)
  • 60%

    • What is a highly sensitive test good at?

    <p>Ruling out patients without a condition</p> Signup and view all the answers

    What is a highly specific test good at?

    <p>Identifying patients without false positives</p> Signup and view all the answers

    What is the significance of a patient's pain not being relieved by bed rest?

    <p>The patient is likely to have cancer</p> Signup and view all the answers

    What is the age below which cancer is not identified in patients with back pain?

    <p>50 years old</p> Signup and view all the answers

    What is an absolute contraindication for HVLA adjusting?

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

    What is the primary purpose of considering cancer until proven otherwise in a patient with a history of cancer?

    <p>To identify the underlying cause of back pain</p> Signup and view all the answers

    What is the significance of unexplained weight loss in a patient with back pain?

    <p>It is a red flag for cancer</p> Signup and view all the answers

    Which of the following is an absolute contraindication to HVLA that may cause radiculopathy?

    <p>Spinal cord or meningeal tumors</p> Signup and view all the answers

    What is the primary purpose of EMG/NCV nerve testing in lumbar radiculopathy?

    <p>To determine the level of spinal nerve involved</p> Signup and view all the answers

    Which of the following is a characteristic of L4 radiculopathy?

    <p>Lateral-anterior thighs wrapping around to antero-medial foreleg</p> Signup and view all the answers

    What is the term for a group of muscles stimulated by a single spinal nerve?

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

    Which of the following is a surgical indication for lumbar radiculopathy?

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

    What is the term for narrowing of the lateral recesses of the spinal canal?

    <p>Foraminal stenosis</p> Signup and view all the answers

    Which of the following muscles is stimulated by the C5 spinal nerve?

    <p>Deltoid and Biceps</p> Signup and view all the answers

    Which of the following is a characteristic of sciatica?

    <p>Pain radiating to the posterior legs and lateral ankles</p> Signup and view all the answers

    What is the primary concern when diagnosing musculo-ligamentous injuries?

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

    What is the typical duration of onset of musculo-ligamentous injuries after trauma?

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

    What is the primary reason for ordering X-rays in musculo-ligamentous injuries?

    <p>To rule out fracture</p> Signup and view all the answers

    What is the contraindication for HVLA in musculo-ligamentous injuries?

    <p>Severe or acute injury</p> Signup and view all the answers

    What is the primary goal of gentle stretching and exercise in musculo-ligamentous injuries?

    <p>To increase circulation and promote flexible healing</p> Signup and view all the answers

    What is the typical referral pattern for facet pain?

    <p>Buttocks and posterior thighs</p> Signup and view all the answers

    What is the primary cause of nerve root irritation in disc degeneration?

    <p>Direct compression</p> Signup and view all the answers

    What is the term for the inflammatory response caused by viral infection in nerve root irritation?

    <p>Rad neuritis</p> Signup and view all the answers

    What is the incidence of LBP caused by spinal infection?

    <p>0.01%</p> Signup and view all the answers

    What is the significance of the presence of fever in a patient with suspected spinal infection?

    <p>It has high specificity for spinal infection</p> Signup and view all the answers

    What is the significance of the acronym 'SPIN' in the context of spinal infections?

    <p>Specificity Positive In</p> Signup and view all the answers

    What is the significance of the acronym 'SNOUT' in the context of spinal infections?

    <p>Sensitivity Negative Outlines Unnecessary Testing</p> Signup and view all the answers

    What is a common risk factor for compression fractures?

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

    What is the significance of a patient being over 70 years old in the context of compression fractures?

    <p>It has high specificity for compression fracture</p> Signup and view all the answers

    What is the significance of long-term corticosteroid usage in the context of compression fractures?

    <p>It has high specificity for compression fracture</p> Signup and view all the answers

    What is the significance of a history of trauma in the context of compression fractures?

    <p>It has high specificity for compression fracture</p> Signup and view all the answers

    What is the specificity of the 'Yes + LBP' test for compression fracture?

    <p>85%</p> Signup and view all the answers

    What is the purpose of the 5 screening questions for Ankylosing Spondylitis?

    <p>To identify patients who require further investigation</p> Signup and view all the answers

    What is the significance of a positive screening test result for Ankylosing Spondylitis?

    <p>It warrants further investigation for Ankylosing Spondylitis</p> Signup and view all the answers

    What is the limitation of the Schober test in the physical examination of Ankylosing Spondylitis?

    <p>It is not specific to Ankylosing Spondylitis</p> Signup and view all the answers

    What is the significance of the spinal ROM in the physical examination of Ankylosing Spondylitis?

    <p>It is very useful in locating spinal fixations, planning, and monitoring physical therapy</p> Signup and view all the answers

    What is a cause of neurologic compromise in patients with low back pain?

    <p>Herniated disc</p> Signup and view all the answers

    What is the primary function of the lumbar area?

    <p>To provide structural support and movement</p> Signup and view all the answers

    Which of the following conditions is NOT a cause of low back pain?

    <p>Cardiovascular disease</p> Signup and view all the answers

    What is the significance of a patient's history of cancer in the context of low back pain?

    <p>It is a red flag for potential underlying pathology</p> Signup and view all the answers

    What is the primary purpose of considering red flags in a patient's history?

    <p>To rule out potential underlying pathology</p> Signup and view all the answers

    What is the characteristic of lumbar strain/sprain?

    <p>It is a common cause of low back pain</p> Signup and view all the answers

    What is the significance of unexplained weight loss in a patient with low back pain?

    <p>It is a red flag for potential underlying pathology</p> Signup and view all the answers

    What is a symptom that is not typically experienced with mechanical back pain, but may indicate a more serious underlying condition?

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

    What is the prevalence of malignant neoplasm of the spine as a cause of low back pain?

    <p>0.7%</p> Signup and view all the answers

    What is the primary purpose of assessing motor, reflex, and sensory function in diagnosing the causes of low back pain?

    <p>To identify evidence of neurologic compromise</p> Signup and view all the answers

    What is the term for the phenomenon where social/psychological stress can amplify or prolong pain?

    <p>Somatic amplification</p> Signup and view all the answers

    What is the significance of finding at least 3 out of 5 categories of inappropriate/non-organic signs in a patient with low back pain?

    <p>It suggests a high likelihood of psychological distress</p> Signup and view all the answers

    What is the primary purpose of considering evidence of social/psychological distress in diagnosing the causes of low back pain?

    <p>To identify evidence of social/psychological stress that could amplify or prolong pain</p> Signup and view all the answers

    What is the term for the inflammatory response caused by viral infection in nerve root irritation?

    <p>Not mentioned in the provided content</p> Signup and view all the answers

    What is the significance of a patient presenting with a sudden onset of severe abdominal/back pain?

    <p>It may indicate a more serious underlying condition, such as aorto-iliac disease</p> Signup and view all the answers

    Which of the following anatomic anomalies is an absolute contraindication to HVLA adjusting?

    <p>Dens hypoplasia</p> Signup and view all the answers

    A patient presents with low back pain and has a history of gallstones. What is the likelihood that the back pain is referred from the gallbladder?

    <p>63%</p> Signup and view all the answers

    Which of the following visceral diseases can cause sharp, referred low back pain?

    <p>Kidney stones</p> Signup and view all the answers

    What is the primary concern when evaluating a patient with back pain and a history of cancer?

    <p>Metastatic disease</p> Signup and view all the answers

    Which of the following anatomic anomalies can cause relative contraindications or no contraindications to HVLA adjusting?

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

    What is the primary reason for evaluating anatomic anomalies in patients with low back pain?

    <p>To identify absolute contraindications to HVLA adjusting</p> Signup and view all the answers

    What is the primary reason for considering cancer until proven otherwise in a patient with a history of cancer?

    <p>To avoid underdiagnosis</p> Signup and view all the answers

    What is the significance of a patient's pain not being relieved by bed rest in the context of cancer?

    <p>It is a strong indication of cancer</p> Signup and view all the answers

    What is the primary purpose of patient history in detecting underlying cancer?

    <p>To identify the underlying cancer compared to physical examination</p> Signup and view all the answers

    What is the sensitivity of the test combining the patient being younger than 50 years and having no history of cancer, unexplained weight loss, or failure of conservative therapy?

    <p>100%</p> Signup and view all the answers

    What is the primary purpose of the WHO Guidelines list of absolute contraindications for HVLA adjusting?

    <p>To prevent injury or harm to patients undergoing HVLA adjusting</p> Signup and view all the answers

    What is the significance of the presence of fever in a patient with suspected spinal infection?

    <p>It indicates a high likelihood of spinal infection</p> Signup and view all the answers

    What is the term for narrowing of the lateral recesses of the spinal canal?

    <p>Lateral recess stenosis</p> Signup and view all the answers

    What is the primary purpose of gentle stretching and exercise in musculo-ligamentous injuries?

    <p>To promote healing and recovery</p> Signup and view all the answers

    What is the significance of a patient being over 70 years old in the context of compression fractures?

    <p>It increases the likelihood of compression fractures</p> Signup and view all the answers

    What is the significance of the acronym 'SNOUT' in the context of spinal infections?

    <p>It stands for 'Sensitive, Negative Outcome, Unlikely, and True'</p> Signup and view all the answers

    What is the main reason why the 'Yes + LBP' test is not used as a diagnostic tool for compression fractures?

    <p>It has low sensitivity</p> Signup and view all the answers

    What is the primary purpose of the 5 screening questions for Ankylosing Spondylitis?

    <p>To identify patients who require further investigation</p> Signup and view all the answers

    What is the limitation of the Schober test in the physical examination of Ankylosing Spondylitis?

    <p>It is not specific to Ankylosing Spondylitis</p> Signup and view all the answers

    What is the significance of a positive screening test result for Ankylosing Spondylitis?

    <p>It warrants further investigation</p> Signup and view all the answers

    What is the main purpose of assessing spinal ROM in the physical examination of Ankylosing Spondylitis?

    <p>To locate spinal fixations and plan physical therapy</p> Signup and view all the answers

    What is a common cause of neurologic compromise in patients with low back pain?

    <p>Herniated disc</p> Signup and view all the answers

    Study Notes

    Musculo-Ligamentous Injuries

    • Low back pain due to soft tissue injury:
      • Local pain on palpation (mild to severe)
      • No paresthesia (exceptions)
      • No muscle weakness in legs or feet
      • Paraspinal muscle spasm (may be excruciating)
      • Relieved by rest, exacerbated by motion
      • May begin immediately or gradually after trauma (usually within 24 hours)
    • Diagnosis based on mechanism of injury (MOI), location of pain, and exclusion of nervous system injury and other systemic diseases

    Chiropractic Care

    • HVLA (high-velocity, low-amplitude) may be contraindicated if severe/acute
    • Limiting motion decreases muscle strength, flexibility, and circulation
    • Gentle stretching and exercise preferred treatment to increase circulation and facilitate healing

    IVD and Facet Degeneration

    • May cause radiating pain if degeneration causes nerve root impingement
    • IVD bulging/herniated into IVF (intervertebral foramen)
    • Facet hypertrophy (severe expanding into IVF)
    • Facet pain referral to:
      • Buttocks and posterior thighs

    Nerve Root Irritation

    • Direct compression (mechanical pressure)
      • Disc degeneration/Lumbar radiculopathy (usually unilateral)
      • Bony encroachment (arthritic hypertrophy, spondylolisthesis, spinal stenosis)
    • Chemical changes:
      • Nucleus pulposus inflammatory to nerve roots
    • Neuroischemia (spinal stenosis)
    • Viral infection:
      • Causes inflammation of the nerves

    Lumbar Radiculopathy

    • Pathology of a lumbar nerve root
      • Herniated disc (degeneration, trauma, or both)
      • Facet arthritis/bone spurs
      • Spondylolisthesis
    • Absolute contraindications to HVLA:
      • Spinal cord or meningeal tumors and cysts
      • Hematomas (cord or spinal canal)
      • Spinal malignancies
      • Aggressive benign tumors
    • Need to determine level involved:
      • Patient history
      • EMG/NCV nerve testing
    • Surgery may be necessary:
      • Unrelenting pain
      • Severe functional impairment
      • Incontinence (CES-SURGICAL EMERGENCY)

    Radiating Pain and Dermatomal Patterns

    • Sciatica (S1-S5):
      • Buttocks → posterior legs → lateral ankles
    • L5:
      • Postero-lateral thighs wrapping around to the anterior foreleg
    • L4:
      • Lateral-anterior thighs wrapping around to antero-medial foreleg

    Myotomes and Muscle Strength Testing

    • Myotome: group of muscles stimulated by a single spinal nerve
    • Upper extremities:
      • C5: Deltoid and Biceps (C6 too)
      • C6: Wrist Extensors
      • C7: Triceps/Wrist Flexors/Finger Extensors
      • C8: Finger Flexors
      • T1: Finger Abduction/Finger Adduction
    • Lower extremities:
      • L3: Hip Flexors
      • L4: Knee Extensors
      • L5: Knee Flexors
      • S1: Plantar Flexors

    Spinal Stenosis

    • Central Canal Stenosis: narrowing of the central spinal canal
    • Foraminal Stenosis (lateral): narrowing of the lateral recesses of the spinal canal

    Cancer Red Flags

    • Patient history:
      • History of cancer
      • Unexplained weight loss
      • Pain lasting longer than one month
      • Pain not relieved by bed rest
    • Specificity and sensitivity:
      • Highly sensitive test: more likely a – test is really – for a condition
      • Highly specific test: more likely + test is really + for condition
    • Cancer summary:
      • Patient history is most useful in detecting underlying cancer
      • >50 yoa
      • History of cancer
      • Unexplained weight loss
      • Pain > one month
      • Pain not improved by conservative therapy
      • Pain not relieved by bed rest

    Absolute Contraindications

    • WHO Guidelines list of absolute contraindications for HVLA adjusting:
      • Some anomalies
      • Acute fracture
      • Acute infection
      • Spinal malignancies
      • Hematomas (cord or canal)
      • Frank disc herniation with accompanying signs of progressive neurological deficit

    Spinal Infections

    • Acute spinal infections are absolute contraindications to HVLA thrusts
    • LBP caused by spinal infection – incidence 0.01%
    • Usually bloodborne
    • Presence of fever: high specificity (SPIN)

    Compression Fractures

    • Red Flags:
      • Osteoporosis
      • Corticosteroid usage
      • >70 yoa
      • >50 yoa
      • History of trauma
    • Specificity = positive rules in
      • Patient > 70 yoa? Yes + LBP = 96% specific for compression fracture
      • Patient > 50 yoa? Yes + LBP = 61% specific for compression fracture
      • Long-term corticosteroid usage? - very high specificity (0.99)
      • Is there a history of trauma? Yes + LBP = 85% specific for compression fracture

    Ankylosing Spondylitis

    • 5 screening questions for AS:
      • Morning stiffness?
      • Discomfort improves with exercise?
      • Onset before 40 yoa?
      • Did symptoms begin slowly?
      • Has the pain persisted for a minimum of 3 months?
    • If the pt answers ‘yes’ to at least 4/5 of the screening questions → + for AS
    • Predictive value of a + screening test is typically low for very rare conditions
    • Sensitivity and specificity vary from one study to another

    Evidence of Neurologic Compromise

    • Causes of neurologic compromise:
      • Herniated disc may compromise neurological structures
      • Cauda equina
      • Spinal cord
      • Nerve root

    Low Back Pain: General Information

    • The low back (lumbar area) provides structural support, movement, and protection of certain body tissues.
    • Pain in the low back can result from conditions affecting the bony lumbar spine, intervertebral discs, ligaments, spinal cord/nerves, lumbar musculature, internal organs, and skin.

    Origins of Low Back Pain

    • Anatomic and physiologic causes:
      • Musculoligamentous injuries
      • Degenerative changes in intervertebral discs (IVD) and facets
      • IVD herniation with nerve root irritation
      • Spinal stenosis
      • Anatomic anomalies
      • Underlying systemic disease
      • Visceral disease
    • Red flags for low back pain:
      • Unsteady when standing or walking
      • Difficulties passing/controlling bladder or bowels or numbness in either area
      • Previous history of cancer or osteoporosis
      • Back pain accompanied by unexplained weight loss or fever
      • Bleeding disorder

    Musculo-Ligamentous Injuries

    • Lumbar strain/sprain (acute/chronic):
      • One of the most common causes of low back pain
      • May present with compensatory hypolordosis
      • Can result from hypertrophic degenerative changes

    Anatomic Anomalies

    • Absolute or relative contraindications:
      • Dens hypoplasia, unstable os odontoideum, basilar invagination, Arnold Chiari, etc.
      • Most lumbopelvic anomalies cause relative contraindications or none
      • Scoliosis – asymptomatic or symptomatic (severe)
      • Spondylolisthesis - asymptomatic or symptomatic (severe)

    Systemic Disease

    • Causes of low back pain:
      • Cancer – primary or metastatic
      • Spinal infections
      • Ankylosing spondylitis

    Visceral Diseases

    • May refer pain to the low back from abdominal and pelvic organs:
      • Bowel/bladder
      • Uterus/ovaries and prostate
      • Kidneys
      • GI (gallbladder, aorta, etc.)
      • Lymph nodes/tissue

    Prevalence of Diseases Causing Low Back Pain

    • Compression fractures: 4%
    • Spondylolisthesis: 3%
    • Malignant neoplasm of the spine: 0.7%
    • Ankylosing spondylitis: 0.3%
    • Spinal infections: 0.01%
    • Spinal stenosis: prevalence unknown (common in older adults)

    Diagnosing Causes of Low Back Pain

    • Evidence of systemic disease or visceral disease, anatomic anomalies:
      • Pt. history/exam
      • Constitutional symptoms
      • Evidence of neurologic compromise (lumbar disc herniation, stenosis, CES)
      • Assess motor, reflex, and sensory function
    • Evidence of social/psychological stress that could amplify/prolong pain:
      • Decrease pain inhibition
      • Somatic amplification serves the patient's needs for economic survival and maintenance of self-esteem
      • Illness behavior

    Cancer Red Flags: Sensitivity and Specificity

    • How likely a patient is to have or not have a condition based on test accuracy:
      • Sensitivity: 31%
      • Specificity: 98%
    • M/C source of spinal malignancy: breast, lung, and prostate
    • Patient history is most useful in detecting underlying cancer (compared to physical examination)
      • >50 yoa
      • History of cancer
      • Unexplained weight loss
      • Pain > one month
      • Pain not improved by conservative therapy
      • Pain not relieved by bed rest

    Cancer Summary

    • Patient history is most useful in detecting underlying cancer (compared to physical examination)
    • In a study of nearly 2000 patients with back pain, no cancer was identified in any patient younger than 50 years and without a history of cancer, unexplained weight loss, or failure of conservative therapy (combined sensitivity 100%)
    • Sensitivity 100% = zero false negatives

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    Description

    This quiz covers the causes, diagnosis, and symptoms of musculo-ligamentous injuries, including soft tissue injuries and low back pain. It also discusses the effects of prolonged bedrest on recovery.

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