Ocs- 3-28 Gi Mid/lower Back Pain

Front 1

With the Biomechanics of the thoracic spine...
The orientation of the ______ allows the greatest motion in rotation

Least amount of motion in the thoracic spine is in? why?

Back 1

facets

extension- minimal glide of the superior articular process on the inferior process by the spinal processes and anterior longitudinal ligaments

Front 2

Mid back pain causes?
Why are X-rays not always necessary?

Back 2

large velocity/force- but mostly degenerative changes which is why X-rays are not necessary

Front 3

What do yo look for in lab evaluations?

Back 3

If Hx of cancer or other problems that could cause viscero somatic pain

Front 4

Viscerosomatic Reflex
What is it again?
What does it cause?

Back 4

Disturbances in the viscera (organs) increases sympathetic outflow to somatic structures
- this causes increased muscle tones at certain points (chapman point changes)
- Also referred pain

Front 5

Name the sympathetic outflow for the following...
a. All that originate from T1-4
b. T1-6

Back 5

a. head/neck, thyroid
b. Mammary, Esophagus, Heart, Lung

Front 6

Name the sympathetic outflow for the following...
a. T5-9
b. T5R
c. T7L
d. T7R

Back 6

a. Stomach, Duodenum/liver
b. Gallbladder
c. Spleen
d. Pancreas

Front 7

Name the sympathetic outflow for the following...
a. Stomach, Duodenum/liver
b. Gallbladder
c. Spleen
d. Pancreas

Back 7

a. T5-9
b. T5R
c. T7L
d. T7R

Front 8

Name the sympathetic outflow for the following...
a. head/neck, thyroid
b. Mammary, Esophagus, Heart, Lung

Back 8

a. All that originate from T1-4
b. T1-6

Front 9

What is a facilitated segment?

Back 9

sustained CNS activity occurs less stimulation is required due to continued previous stimulation resulting in the somatic dysfunctions we find

Front 10

What are causes (general categories) of mid back pain? (6)

Back 10

1. Musculoskeletal
2. GI
3. GU
4. Pulmonary
5. Cardiac
6. Other- viruses, cancers, aneurysms

Front 11

What are the GI causes of mid back pain?

Back 11

IBS, GERD, PUD, Gall Bladder

Front 12

What might cause itchy burning type pain in someone with thoracic pain?

Back 12

Herpes Zoster

Front 13

Name the main musculoskeletal mimicking pathologies for mid back pain (5)

Back 13

PPURK
Pancreatitis
Pelvic Infections
UTI's
Reproductive tract dysfunction
Kidney Stones

Front 14

If you were to summarize the order of the evaluation and work up of someone with back pain... what do we have? (Physical)

Back 14

Start with...
1. Posture‐‐static
2. Seated- Para‐spinal evaluation (C, T, L spine), ribs, maybe check upper extremity
3. Supine- C spine assessment, ribs, Pelvic Rock, ASIS/PSIS, leg length, LE eval ‐ fibular head, foot, ankle
4. Prone, Sacrum, Further para‐spinal evaluation (T, L spine), ribs

Front 15

What are some red flags to mid back pain?
What is most common back pathology for someone 20-29?

Back 15

Any pain from someone
<10 yr old think scoliotic problems, CA, intervertebral diskitis (aggrevated by activities)
20-29 disk injury

Front 16

What is the most likely anatomical problems with the 60-69 yr old group?

Back 16

Spinal stenosis, degenerative problems, and tumors

Front 17

What are two markers for palpation in thoracic spine?
What attaches to the upper/lower parts of the 12th ribs?

Back 17

T3- spine of scapula
T7- inferior angle of scapula
- diaphragm upper and quadratus lumborum attaches to the lower

Front 18

If you ranked lower back pain (LBP) what is it as far as how common reason for visit? (in US)
How long before it is considered chronic?

Back 18

5th most common in US

- 6 weeks

Front 19

What do you have rule out for lower back first?

If Hx of drug abuse what is possible likely cause of LBP?

Back 19

bowel or bladder changes
- Emergency because it may be Cauda Equina Syndrome

- drug use think spinal infection

Front 20

When getting the history from the patient with lower back pain how do you classify if the pain is...
a. Acute LBP
b. Acute radiculopathy
c. Chronic radiculopathy

Back 20

1. Acute LBP ‐ pain that does not radiate past knee for less than 6 weeks
2. Acute Radiculopathy – LBP with radiation past the knee for less than 6 weeks
3. Chronic Radiculatopthy ‐ LBP with radiation past the knee for more than 6 weeks

Front 21

What strength tests are used for LBP?

Back 21

Ankle dorsiflexion
Great toe dorsiflexion
Plantar flexion
Hip flexor

Front 22

What are the classic D/D of LBP?

Back 22

1. Low back strain/sprain
2. Lumbar disc herniation
3. Lumbar spinal stenosis
4. DDD (degenerative disc disease)
5. Spondylolisthesis

Front 23

For the physical exam of a pt with LBP what are the processes?

Back 23

1. Palpate for tenderness on spine
2. Posture/range of motion
3. Strength testing (heels, plantars, flexors)
4. Reflex testing (ankle, knee)
5. Sensory testing

Front 24

Strain vs sprain?

Back 24

Strain- musclulature
Sprain- ligaments

Front 25

What are the diagnostic tests for LBP most likely due to lower back strain/sprain?

Back 25

– Reliance on comprehensive physical exam
– Complete neurologic assessment
– Straight leg raising tests
• Higher sensitivity for levels L5, S1
– Plain radiographs rarely assist in diagnosis

Front 26

Treatment for lower back strain/sprain
a. acute phase *days-1-2weeks*
b. subacute phase

Back 26

a. Soft tissue OMT, ROM,
• Pharmacologic‐‐NSAIDS, muscle relaxants, strongly consider spinal manipulation

b. More aggressive OMT as needed, aerobic conditioning
and strength training
• Usually about 4 weeks to recovery

Front 27

Ligamentous support portion of the intervertebral disk
• Disk does not herniate into the spinal canal, but leakage
from the nucleus pulposus can cause localized
inflammation affecting nerve roots
• May weaken with repeated small tears

Back 27

annulus fibrosis

Front 28

What causes the problems with an annulus fibrosis?

Back 28

Annulus fibrosus is the ligamentous portion in the disks
- leakage from the nucleus pulposus cause localized inflammation affecting nerve roots

Front 29

What is going on

Back 29

annulus fibrosis

Front 30

Acute phase treatment of Lumbar disk herniation...

Back 30

• Soft tissue OMT
• NSAIDS
• Muscle relaxants
• Narcotic medications
• Behavior modification
• Oral steroids or epidural injections may benefit

Front 31

Compare an annulus fibrosis with an actual lumbar disk herniation...

Back 31

Annulus fibrosis is when nucleus pulposis leaks out causing an inflammatory reaction
- disk herniation is when the nucleus pulposus extrudes through annulus fibrosis

Front 32

With lumbar disk herniation what symptoms do you want to keep eye out for that resemble Cauda equina syndrome?

Back 32

• Urinary overflow incontinence
• Perianal numbness
• Reduced anal sphincter tone
• Bilateral involvement
• Motor/Sensory Deficits

Front 33

Where do lumbar disk herniations usually occur?

Symptoms?

Back 33

L4-5 or L5-S1 on posterolateral portion which allows bulging or herniation into the lumbar canal
- usually abrupt with unilateral radicular (past knee and lower back) pain

Front 34

What is diagnostic image for disk herniation?
But what would cause you to order this test?

Back 34

MRI

- intolerable pain, or neurological changes

Front 35

How do DDD progress?
What does it lead to?

Back 35

Nucleus pulposus looses hydrophilic properties, disk height lessens, and ligaments become loose
– Twisting and bending can tear anulus fibrosus
– Leads to chronic low back pain and osteoarthritis

Front 36

What symptoms does DDD present?
What makes it worse? better?
What could long term pain cause other than structural probs?

Back 36

low back pain radiating to the butt
- made worse by bending, lifting, stooping, or twisting
- relieved by lying down
- could lead to depression

Front 37

In the physical exam of someone with DDD what would you findings most likely show?

Back 37

– Lumbar and sacral tenderness
– Paravertebral muscle spasms
– Motor and sensory function, reflexes are normal
– Straight leg raising and ROM mildly restricted

Front 38

For DDD what are the diagnostic tests ordered?

Back 38

Ap and lateral radiographs show...
a. • Anterior osteophytes
b. Reduced disk height
c. Occasional “vacuum sign” (nitrogen in disk space)

Front 39

What is the treatment for DDD?

Back 39

– Chronic pain management
– Facet injections
– OMT
– NSAIDS/non‐narcotic pain meds
– Antidepressants to modulate pain perception
– Weight reduction
– Exercise prescription
– Smoking cessation

Front 40

Narrowing of one or more levels of the lumbar spinal canal and subsequent compression of the nerve roots. Few have symptoms, must be anatomically severe for symptoms to be present

Back 40

lumbar spinal stenosis

Front 41

Forward slippage of a lumbar vertebral body
Where does this slippage usually occur on spine?

Back 41

spondylolisthesis- usually L4 and L5

Front 42

If a physical shows...
-Diminished lumbar lordosis and flattening of the gluteal region
– Step‐off of spinous process with a significant one
– Marked hamstring tension and very limited straight leg raising
What is most likely diagnosis?

Back 42

thinking spondylolisthesis "You've got a spondy!"

Front 43

What is the general treatment for spondylolisthesis?

Back 43

– Flexion exercises, stretching exercises
– OMT as with spinal stenosis
– Intermittent NSAID use as needed
– May need to wear back brace or have surgery if the condition becomes severe

Front 44

What is the level usually find spondylolithesis?
Is it different for pediatric?

Back 44

L4-5
Peds- L5-S1

Front 45

Back 45

Front 46

During a physical exam of someone with spondylolsthesis...
What should cause pain?
What are diagnostic radiographs?

Back 46

Pain- flexion and extension
- AP and lateral are adequate, but may want MRI to see canal space changes and oblique view to to rule out spondylolysis