Cbl 1 Low Back Pain

Front 1

Discogenic pain affects extension or flexion more ?

Back 1

flexion

Front 2

mechanical back pain affects extension or flexion more?

Back 2

extension

Front 3

Straight leg raise of his left leg is limited to about 30 degrees because of pain on the left side of his back and down the posterior aspect of his left thigh to his left knee. Is this a positive straight leg result?

Back 3

No, the pain should extend beyond the knee into the calf and to his toe to be sciatica. The shooting pain is often reproduceable by testing the contra lateral leg.

Front 4

should imaging be ordered for low back pain w a duration of 6 weeks?

Back 4

No imaging unless signs of "red flags"

Front 5

what are red flags? List them.

Back 5

Signs of underlying systemic disease causing back pain.
• history of significant trauma
• neurologic deficits
• systemic symptoms
• fever
• unexplained weight loss
• history of cancer
• history of prolonged corticosteroid use
• drug or alcohol abuse
• suspected ankylosing spondylitis.

Front 6

What are yellow signs?

Back 6

Psychosocial and sociological factors that increase the risk of developing or perpetuating long-term disability and work loss associated with low back pain..
• belief that back pain is harmful or potentially severely disabling
• fear and avoidance of activity or movement
• tendency to low mood and withdrawal from social interaction
• problems and/or dissatisfaction at work
• expectation of passive treatment(s) rather than a belief that active participation will help.

Front 7

How do you approach an examination of lower back pain?

Back 7

Observation, palpation, Range of motion, muscle strength, reflexes.

Front 8

what would you be looking for on Observation?

Back 8

asymmetry, skin, leg-length discrepancy, lumbar lordosis, Trendelenburg, antalgic gait, toe walking, heel walking;

Front 9

what would you be looking for on Palpation?

Back 9

spinous processes, paraspinal muscles, sacroilliac joints;

Front 10

what would you be testing for Range of motion ?

Back 10

forward flexion, extension, lateral flexion, rotation, FABER (flexion, abduction, external rotation of the hip), hip flexion, straight leg raise (Lasègue test), cross straight leg raise

Front 11

Where would you be checking muscle strength?

Back 11

L4, L5, S1

Front 12

Which reflexes would you test?

Back 12

Patellar tendon (L4), Achilles tendon (S1

Front 13

What is a DDx in the low back pain case?

Back 13

Back strain, acute disc herniation, spondylolysis or spondylolisthesis.

Front 14

Describe the anatomy of the lumbar spine.

Back 14

5 lumbar vertebra could have 6.

Front 15

Describe the anatomy of the lumbar spine including associated dermatomes.

Back 15

98 percent of clinically important disc herniations occur at L4-5 and L5-S1
L5 motor nerve root testing evaluates strength of ankle and great toe dorsiflexion. L5 sensory nerve root damage would result in numbness in the medial foot and the web space between the first and second toe.
The S1 nerve root is tested by evaluating ankle reflexes and sensation at the posterior calf and lateral foot. S1 radiculopathy may cause weakness of plantar flexion, but is difficult to detect until quite advanced. One strategy is to have the patient raise up on tip-toe three times in a row, on one foot alone and then the other.
Although ankle reflexes are an important part of S1 nerve root testing, the absence of ankle reflexes becomes increasingly common with age. Among patients without a known pathologic cause of abnormal reflexes, most patients under age 30 have intact ankle reflexes

case: Inflammation and irritation around L5/S1 nerve roots

Front 16

Describe the anatomy of the lumbar spine including associated myotomes.

Back 16

• L2: Hip flexion
• L3 :knee extension
• L4: Ankle dorsiflexion
• L5: Great toe extension
• S1: AnkIe plantar flexion, ankle eversion, hip extension
• S2: Knee flexion

Front 17

What are Waddels signs?

Back 17

Superficial and non-anatomic tenderness
inconsistent responses with distraction (e.g. normal straight leg raises in the sitting position)
non-dermatomal sensory loss
overreaction.

Front 18

How should acute low back pain around 4 weeks be managed?

Back 18

Self-care
medication (acetaminophen and NSAIDs)
activity modification (he should avoid painful arcs of motion and tasks that exacerbate the back pain).

Front 19

What are light duties?

Back 19

Sedentary work or work that does not require him to lift objects greater than 5 kg

Front 20

at 12 weeks without improved symptoms, in the case, would you order imaging?

Back 20

No. In the absence of “red flags,” evidence indicates that laboratory tests and diagnostic imaging are ineffective or harmful. (controversial fr. tutor response)

Front 21

what other health care workers might pt with low back pain benefit from seeing?

Back 21

Physiotherapy, TENS, massage therapy, acupuncture. Consider behavioural therapy.

Front 22

recommended pharmacotherapy? tx acute low back pain

Back 22

1st line - acetominophen up to 1000mg QID
2nd line = NSAIDs (ibuprofen or didofenac)
ADD = cyclonemzapine for prominent muscle spasm.
if taking controlled release opiods add a short acting opiod or increase controlled release optiod by 20-25%

Front 23

recommended pharmacotherapy? tx chronic low back pain

Back 23

1st line - acetominophen up to 1000mg QID
2nd line = NSAIDs (ibuprofen or didofenac)
3rd line = Tricyclics (TCA) (amitriptyline, nortriptyline)
3rd line = weak opiods (codeine)
4th line = tramadol - slow titrations w max 400mg/day. monitor daily acetominophen when using combined w tramadol.