Types of Low Back Pain

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Questions and Answers

What is the most common cause of lumbar radiculopathy?

Herniated disc (correct)

Sacroiliitis

Osteoporotic compression fracture

Greater trochanter bursitis

Which of the following conditions is considered serious and emergent, requiring rapid treatment?

Neoplasms (correct)

Osteoporotic compression fracture

Spondylosis

Inflammatory arthritis

What is the primary difference between mechanical and degenerative causes of low back pain?

Degenerative causes are more rare

Mechanical causes are acute, while degenerative causes are chronic (correct)

Mechanical causes are more severe

Degenerative causes are more chronic

Which of the following is an example of an inflammatory cause of low back pain?

Sacroiliitis Signup and view all the answers

What is the primary concern when evaluating a patient with acute low back pain and radiculopathy?

Ruling out cauda equina syndrome Signup and view all the answers

Which of the following is an example of a visceral disease that can cause low back pain?

Renal structures disease Signup and view all the answers

What is the estimated prevalence of lumbosacral radiculopathy in the population?

3-5% of population Signup and view all the answers

What is the most common type of lumbar radiculopathy?

L5 radiculopathy Signup and view all the answers

What is the typical pain experience of patients with lumbosacral radiculopathy?

Tingling, electric, burning or sharp pain Signup and view all the answers

What is a risk factor for lumbosacral radiculopathy?

Repetitive lifting and twisting motions Signup and view all the answers

What is an important aspect to assess during history intake for lumbosacral radiculopathy?

Dermatomal distribution of pain Signup and view all the answers

What is typically worse with increased intradiscal pressure in patients with lumbosacral radiculopathy?

Pain Signup and view all the answers

What percentage of patients with lumbar disc herniation experience relief within 6-12 weeks without treatment?

85-90% Signup and view all the answers

What is the characteristic of a bulging disc?

Loss/damage of annular fibers allows the nucleus pulposus to shift without herniation Signup and view all the answers

What is the prognosis for a herniated disc - protrusion without treatment?

Regression: 41%, Complete Disappearance: 0% Signup and view all the answers

What is the characteristic of a herniated disc - extrusion?

Nucleus palposus breaks through the annulus fibrosus Signup and view all the answers

What is the prognosis for a herniated disc - sequestration without treatment?

Regression: 70%, Complete Disappearance: 15% Signup and view all the answers

What is the significance of contralateral pain at less than 45o in a crossed SLR test?

Positive for lumbar disc herniation Signup and view all the answers

In L5 radiculopathy, which of the following findings has the highest sensitivity?

Asymmetric medial hamstring reflex Signup and view all the answers

In S1 radiculopathy, which of the following is a common area of paresthesia/sensory change?

Sole, lateral foot and ankle, and fourth and fifth toes Signup and view all the answers

In L5 radiculopathy, which of the following has a likelihood ratio (LR+) of 3.1?

Sensory loss in L5 distribution Signup and view all the answers

In S1 radiculopathy, which of the following reflexes is often absent?

Ankle reflex Signup and view all the answers

In S1 radiculopathy, which of the following motor weakness is commonly seen?

Plantar flexion of the foot Signup and view all the answers

In L5 radiculopathy, which of the following has a likelihood ratio (LR-) of 0.7?

Weak hallux extension Signup and view all the answers

What is the term for the degeneration of the vertebral bodies, joints, and foramina due to wear and tear?

Spinal osteoarthritis Signup and view all the answers

What is the condition characterized by the slippage of one vertebral body with respect to the adjacent vertebral body?

Spondylolisthesis Signup and view all the answers

What percentage of people between 60-69 years old have spinal stenosis?

19.4% Signup and view all the answers

What is the term for weakness or stress fracture through the pars interarticularis?

Spondylolysis Signup and view all the answers

What is the term for the age-related degeneration of the spinal column?

Spondylosis Signup and view all the answers

What is the symptom of spinal stenosis that depends on the affected nerve root?

Numbness or loss of strength in the lower extremities Signup and view all the answers

What is a characteristic of a person with a panic disorder during a mental status examination?

Disheveled appearance and fast speech Signup and view all the answers

What is a common cognitive distortion in individuals with panic disorder?

Ruminations about the consequences of their panic attacks Signup and view all the answers

What is a criterion for diagnosing panic disorder?

Having at least one month of persistent concern or worry about additional panic attacks or their consequences Signup and view all the answers

What is a common behavioral change in individuals with panic disorder?

Maladaptive avoidance behaviors Signup and view all the answers

What is a typical affective state in individuals with panic disorder?

Anxious, afraid, and tense Signup and view all the answers

What is a question asked in the PHQ-PD module?

In the last 4 weeks, have you had an anxiety attack with sudden fear or panic? Signup and view all the answers

What is the purpose of the PHQ-PD and ANS questionnaires?

To screen for panic disorder Signup and view all the answers

What is the sensitivity of the ANS questionnaire in identifying panic disorder?

94-100% Signup and view all the answers

What is adjustment disorder?

A maladaptive emotional and/or behavioural response to an identifiable psychosocial stressor Signup and view all the answers

What is the prevalence of adjustment disorder in the general population?

1-2% Signup and view all the answers

What is the typical timeline for the onset and resolution of adjustment disorder?

Onset shortly after stressor, resolving within 6 months Signup and view all the answers

What is the prognosis for patients with adjustment disorder?

71% recover within 5 years Signup and view all the answers

What is the prevalence of other specified depressive disorder?

2-16% Signup and view all the answers

What is the duration of symptoms for a diagnosis of persistent depressive disorder (PDD)?

At least 2 years Signup and view all the answers

What is the risk factor for other specified depressive disorder?

Female, Hx of anxiety Signup and view all the answers

What is the prognosis for other specified depressive disorder?

21 years Signup and view all the answers

What is the diagnostic criteria for PDD according to DSM-5?

Depressed mood for most of the day, more days than not, for at least 2 years Signup and view all the answers

What is the management for other specified depressive disorder?

Patient education, referral to psychotherapy Signup and view all the answers

What is the primary purpose of the PHQ-9 questionnaire?

To assess the severity of depression and anxiety symptoms Signup and view all the answers

How often are individuals asked to rate their experiences in the PHQ-9 questionnaire?

Over the past 2 weeks Signup and view all the answers

What is the next question asked after the PHQ-9 item assessment?

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Signup and view all the answers

What is the scale used to rate the frequency of experiences in the PHQ-9 questionnaire?

Not at all, Several days, More than half the days, Nearly every day Signup and view all the answers

How many items are assessed in the PHQ-9 questionnaire?

8 Signup and view all the answers

What is the purpose of the PHQ-9 questionnaire in a clinical setting?

To assess the severity of depression and anxiety symptoms and monitor treatment response Signup and view all the answers

What is the primary purpose of assessing the severity of disease in a patient's mental health assessment?

To evaluate the patient's functional capacity and impact on daily life Signup and view all the answers

What is the term for the systematic review of a patient's mental status, including appearance, behavior, and thought processes?

Mental Status Examination Signup and view all the answers

Which of the following is an example of a subjective data point in a patient's mental health assessment?

Onset of symptoms Signup and view all the answers

What is the purpose of using a screening tool, such as the GAD-7, in a patient's mental health assessment?

To identify potential symptoms of anxiety or other mental health conditions Signup and view all the answers

What is the importance of assessing a patient's cognitive function, such as thought process and content, in a mental health assessment?

To understand the patient's perception of their symptoms and mental health Signup and view all the answers

What is the term for the process of using sensitivity, specificity, and likelihood ratios to influence the threshold for diagnosis and treatment in medical decision making?

Threshold Model of Medical Decision Making Signup and view all the answers

Study Notes

Classification of LBP

LBP due to mechanical spine problems: lumbar radiculopathy, spinal stenosis, cauda equina syndrome
LBP due to systemic disease affecting the spine: neoplasms, infection, osteoporotic compression fracture, inflammatory arthritis
LBP due to visceral disease: pelvic, renal, GI structures

Ddx of Acute LBP with Radiculopathy

Mechanical: spinal fracture, lumbar disc herniation, cauda equina syndrome, piriformis syndrome, Iliotibial band syndrome
Degenerative: spinal stenosis, spondylosis, spondylolisthesis, facet arthropathy, pseudoclaudication
Inflammatory: sacroiliitis, greater trochanter bursitis, ankylosing spondylitis
Oncologic: spinal neoplasms (most commonly metastatic)
Infectious: vertebral lesion (infection, e.g. S1

Epidemiology of LBP with Radiculopathy

Prevalence: 3-5% of population
Male > female (3:2), especially in those over 40 and 50 years old respectively
L5 radiculopathy is the single most common lumbar radiculopathy
Pain experience: tingling, electric, burning or sharp, paresthesia (63-72%), radiation of pain into lower limb (35%), numbness (27%), muscle weakness (up to 37%), absent ankle reflexes (40%), absent knee reflexes (18%)

Risk Factors for LBP with Radiculopathy

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

History Intake for LBP with Radiculopathy

Site: location of back pain
Onset: how and when back pain developed
Quality: throbbing, aching, sharp, dull, burning, pressure, numbness, tingling, or shooting
Radiation: dermatomal distribution
Time course: change in back pain over time
Severity: 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, saddle anaesthesia (if cauda equina syndrome is possible)

Patterns of Disc Herniation

Bulging disc: loss/damage of annular fibers, associated with trauma, repetitive stress or aging, prognosis: regression (13%), complete disappearance (11%)
Herniated disc - protrusion (prolapse): focal distension of the disc, annulus fibrosis remains intact, prognosis: regression (41%), complete disappearance (0%)
Herniated disc - extrusion: nucleus palposus breaks through the annulus fibrosis, remains in the disc, prognosis: regression (70%), complete disappearance (15%)
Herniated disc - sequestration: nucleus palposus breaks through the annulus fibrosis, displaced from the site of extrusion

L5 Radiculopathy

Findings: weak hallux extension (sensitivity: 12-62%, LR+: 1.7, LR-: 0.7), weak ankle dorsiflexion, sensory loss in L5 distribution (sensitivity: 20-52%, LR+: 3.1, LR-: 0.8), asymmetric medial hamstring reflex (sensitivity: 57%, LR+: 6.2, LR-: 0.5)

S1 Radiculopathy

Distribution of pain: 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)
Findings: weak ankle plantar flexion (sensitivity: 26-45%, LR+: NS, LR-: 0.7), ipsilateral calf wasting (sensitivity: 43%, LR+: 2.4, LR-: 0.7), sensory loss in S1 distribution (sensitivity: 32-49%, LR+: 2.4, LR-: 0.7), asymmetric achilles reflex (sensitivity: 45-91%, LR+: 2.7, LR-: 0.5)

Serious Disorders Affecting the Lumbar Spine

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

Panic Disorder

Diagnostic criteria: recurrent, unexpected panic attacks with 4 or more of the following symptoms:
- Palpitations, pounding heart, or accelerated heart rate
- Sweating
- Trembling or shaking
- Sensations of shortness of breath or smothering
- Feelings of choking
- Chest pain or discomfort
- Nausea or abdominal distress
- Feeling dizzy, unsteady, light-headed, or faint
- Chills or heat sensations
- Paresthesias (numbness or tingling sensations)
- Derealization (feelings of unreality) or depersonalization (being detached from oneself)
- Fear of losing control or "going crazy"
- Fear of dying
At least one of the attacks has been followed by 1 month (or more) of:
- Persistent concern or worry about additional panic attacks or their consequences
- Significant maladaptive change in behavior related to the attacks

Mental Status Examination (MSE)

Appearance and behavior: may present as well-kempt or disheveled
Motor activity: may have psychomotor agitation
Speech: may be fast or pressured; if in a panic attack, may have difficulty speaking (stammering, vocal tremor)
Affect and mood: may describe mood as anxious, afraid, tense, exhausted, frustrated, "on edge", or irritable; or depressed
Thought process: may include ruminations
Thought content: extreme fear, sense of impending doom (in an attack); anticipatory anxiety about having another attack (between attacks)
Perception: often a negative view of themselves and of the world
Sensorium and cognition: may have difficulty concentrating, mind blank, or confused during an attack
Insight: often aware fears are out of proportion to the actual threat
Judgement: tend to use avoidance behaviors

PHQ-PD Module

Questions to assess panic disorder:
- Have you had an anxiety attack with sudden fear or panic in the last 4 weeks?
- Has this ever happened before?
- Do some of these attacks come suddenly, out of the blue, in situations where you do not expect nervousness?
- Do these attacks bother you a lot or are you worried about having another attack?
- Have you had these symptoms during your last bad anxiety episode?

Autonomic Nervous System (ANS) Questionnaire

Questions to assess panic disorder:
- Have you ever had a spell or an attack when all of a sudden you felt frightened, anxious, or very uneasy?
- Have you ever had a spell or attack when for no reason your heart suddenly began to race, you felt faint, or you couldn't catch your breath?

Panic Disorder Screening Questionnaires Scoring

PHQ-PD (1- or 5-item) and ANS can be used to screen for panic disorder
Severity often assessed using a different questionnaire (e.g. PDSS-SR)
Likelihood ratios to identify panic disorder (PD) using PHQ-PD 1, PHQ-PD 5, and ANS questionnaires

Adjustment Disorder

Definition: a maladaptive emotional and/or behavioral response to an identifiable psychosocial stressor
Prevalence: 1-2% (general), 5-20% (outpatient mental health visit), 27% (recently unemployed), 18% (bereaved)
Risk factors: significant life event(s)
Diagnosis: by clinical interview (according to DSM-5 criteria), no validated assessment tools
Timeline: onset shortly after stressor, typically resolves within 6 months after stressor has stopped (or becomes classified as 'chronic adjustment disorder')
Character: with anxiety, depressed mood (may include suicide attempt), mixed, with misconduct, or unspecified
Management: patient education, referral to psychotherapy, psychiatry
Prognosis: 71% recover within 5 years, 76% comorbidity with substance abuse

Other Disorders

Stress: a physical or mental response to an external stressor, considered a risk factor, an exacerbating factor, and a treatment target – not a diagnosis itself
Depressed mood: a depressive syndrome that causes distress and psychosocial impairment for at least 2 weeks, but is not considered clinical depression (aka. major depression)
Dysthymic disorder: depressed mood for most of the day, more days than not, for at least 2 years

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Description

Identify the causes of low back pain, including lumbar radiculopathy, spinal stenosis, and visceral disease. Understand the differences between serious and emergent conditions.