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Low Back Pain in the Adult

- Discussion:
    - 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;
    - references:
          - 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;
    - diskography:
              - 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;

- Management:
    - 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;
           - references:
                   - High dose methlprednisolone prevents extensive sick leave after whiplash injury: a prospective randomized double blinded study.
    - references:
           - 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.

Advances in 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.

Back pain and sciatica.                                                       

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