- low back pain is the second most common symptomatic reason for physician visits (followed by URTI)
- diff dx:
- waddel criteria:
- Exam of Lumbar Spine:
- exam of C-Spine:
- neuro exam
- general assessment:
- note patients general body habitus (thin / obese) and posture;
- note an limb length descrepancies and whether the patient's shoes show excessive signs of asymmetrical wear;
- hip exam:
- its important to note that many cases of low back pain ("buttocks pain") actually arises from hip DJD;
- internally and externally rotate the hip inorder to try to "recreate" the patient's symptoms;
- check for hip flexion contracture (Thompson test) which often leads to lumbar lordosis;
- Ipsilateral sciatica on femoral nerve stretch test is pathognomonic of an L4/5 disc protrusion.
- The femoral nerve traction test with lumbar disc protrusions.
- The knee flexion test: a new test for lumbosacral root tension.
- Radiographic Studies:
- bone scan:
- may help rule out infection or occult metastatic tumor;
- may be indicated once the decision to operate has been made;
- may help determine how many levels need to be fused;
- reproduction of patient's symptoms during discography at one or more specific disc levels (and negative response to injection
at least one other level) is reported to accurately correlate w/ good results from multilevel fusion;
- discogram will also help evaluate annular tears;
- CT myelogram:
- allows accurate assesment of lumbar stensosis;
- can detect far lateral disc herniation;
- MRI of Spine:
- Lab Studies:
- in high risks patients (or in low risk patients whose back pain has not improved after an
appropriate period of non operative treatment), a CBC and sed rate should be ordered
to help rule out infection and/or occult metastatic tumors;
- treatment of low back pain should be based on the diagnosis;
- when a specific diagnosis cannot be made, then patients should be managed w/ NSAIDS, 1-2 days of bed rest,
followed by a back education program;
- methods that have not been proven effective in prospective randomized-control studies include:
- acupuncture, massage, manipulation, traction, braces, biofeedback, and/or heat;
- special situations:
- ligamentous cervical spine pain following MVA (whiplash);
- as noted by Spitzer et al (1998), MVA patients who sustained whiplash type injuries,
had a faster recovery when given early high dose steroid (30 mg/kg/hr for 15 min
followed by 5.4 mg/kg/hr for 23 hours;
- treatment needs to be started within 8 hours of injury;
- High dose methlprednisolone prevents extensive sick leave after whiplash injury: a prospective randomized double blinded study.
- Scientific approach to the assessment and management of activity related spinal disorders. A monograph for clinicians. Report of the Quebec Task Force on Spinal Disorders.
- A prospective, randomized, double-blind evaluation of trigger-point injection therapy for low-back pain.
- The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study.
Electrophysiologic mapping of the segmental anatomy of the muscles of the lower extremity.
Recognizing specific characteristics of nonspecific low back pain.
Predictors of low back pain disability.
Predicting disability from low back pain.
The facet syndrome. Myth or reality
Medical Progress: Back Pain And Sciatica.