- 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.
Medical Progress: Back Pain And Sciatica.