Low Back Pain

Neuro exam

- typically normal if only lumbosacral involvement -abnormal nuero exam: R/O lumbar radiculopathy compression, inflammation and/or injury to a spinal nerve root

Diagnostic Tests: CT or MRI

-radiculopathy (pinched nerve) numbness/tingling -s/s do not improve after conservative therapy

Red Flags for Tumor or infection

< 20 or > 50 unexplained weight loss or fever recent bacterial infection, IV drug use, immunosuppression increased pain with rest history of cancer

Which test is demonstrated when the examiner applies pressure to the top of the head with the neck bending forward, producing pain or numbness in the upper extremities? A. Spurling B. McMurry C. Lachman D. Newman

A. Spurling

Early neurological changes in patients with lumbar radiculopathy include: A. loss of keep tendon reflexes. B. poor two-point discrimination. C. reduced muscle strength. D. foot drop.

A. loss of keep tendon reflexes.

Risk factors for lumbar radiculopathy include all of the following except: A. male gender B. Age < 50 years. C. overweight. D. cigarette smoking.

B. Age < 50 years.

You see a 54 year old man complaining of low back pain and is diagnosed with acute lumbosacral strain. Which of the following is the best advice to give about exercising? A. You should not exercise until you are free of pain. B. Back-strengthening exercises can cause mild muscle soreness. C. Electric-like pain in response to exercise is to be expected. D. Conditioning exercises should be started immediately.

B. Back-strengthening exercises can cause mild muscle soreness.

Risk factors for the development of low back pain include all of the following except: A. older age B. carpal tunnel syndrome C. scoliosis D. spinal stenosis

B. carpal tunnel syndrome

When considering the use of muscle relaxants for treatment of low back pain in a 46 yr old construction worker, the NP advises all of the following except: A. these agents have abuse potential B. must be used consistently for 2 weeks to see effects C. use at night can improve sleep D. caution should be used when operating heavy machinery while on these meds

B. must be used consistently for 2 weeks to see effects

A patient with a lumbosacral strain will typically report: A. numbess in the extremities B. stiffness, spasm, and reduced ROM C. "electric" sensation running down one or both legs D. pain at its worst when in sitting position

B. stiffness, spasm, and reduced ROM

The most common sites for lumbar disk herniation are: A. L1 to L2 and L2 to L3. B. L2 to L3 and L4 to L5. C. L4 to L5 and L5 to S1. D. L4 to S1 and S1 to S2.

C. L4 to L5 and L5 to S1.

With the straight-leg-raising test, the NP is evaluating tension on which of the following nerve roots? A. L1 and L2 B. L3 and L4 C. L5 and S1 D. S2 and S3

C. L5 and S1

Loss of Achilles tendon reflex most likely indicates a lesion at: A. L1 to L2. B. L3 to L4. C. L5 to S1. D. S2 to S3.

C. L5 to S1.

Loss of posterior tibial reflex often indicates a lesion at: A. L3. B. L4. C. L5. D. S1.

C. L5.

Which of the following tests yields the greatest amount of clinical information in a patient with acute lumbar radiculopathy? A. lumbosacral radiograph series B. ESR measurement C. MRI D. bone scan

C. MRI

Most episodes of low back pain are caused by: A. an acute precipitating event. B. disk herniation. C. muscle or ligamentous strain. D. nerve impingement.

C. muscle or ligamentous strain.

A patient with sciatica will typically report: A. loss of bladder control. B. stiffness, spasm, and reduced ROM C. shooting pain that starts at the hip and radiates to the foot. D. pain at its worst when lying down.

C. shooting pain that starts at the hip and radiates to the foot.

Which of the following non-pharmacologic methods is least helpful in preventing low back pain reoccurrence? A. low-impact exercise B. toning exercises C. weekly ice baths D. massage therapy

C. weekly ice baths

Approximately what percent of patients experiencing low back pain will have the symptoms resolve within 1 month without specific therapy? A. 33% B. 57% C. 78% D. 90%

D. 90%

The most common site for cervical radiculopathy is: A. C3 to C4. B. C4 to C5. C. C5 to C6. D. C6 to C7.

D. C6 to C7.

You see a 37 year old man complaining of low back pain consisting of stiffness and spasms but without any sign of neurologic involvement. You recommend all of the following interventions except: A. application of cold packs for 20 minutes 3 - 4 times aday. B. use of NSAIDs or acetaminophen for pain control. C. initiation of aerobic and toning exercises. D. bed rest for at least 5 days

D. bed rest for at least 5 days

When considering the use of opioids for low back pain, consider all of the following except: A. patients should be evaluated for abuse potential B. common adverse effects include sedation and constipation C. Limited to patients with severe back pain or pain refractory to other medications D. opioids should be combined with NSAIDs for greatest effect

D. opioids should be combined with NSAIDs for greatest effect

Immediate diagnostic imaging for low back pain should be reserved for all of the following except: A. presence of signs of the cauda equina syndrome. B. presence of severe neurologic deficits. C. presence of risk factors for cancer D. presence of moderate pain lasting at least 2 weeks

D. presence of moderate pain lasting at least 2 weeks

Common causes of sciatica include all of the following except: A. herniated disk. B. spinal stenosis. C. compression fracture. D. soft tissue abnormality.

D. soft tissue abnormality.

Management of Low back pain or Neck Pain with normal neuro exam: Nonpharmacologic

Ice and heat Exercises Massage

Prompt Referral**

Limb, Bowel or bladder dysfunction

Relieves back pain

Lying supine

Management of Low back pain or Neck Pain with normal neuro exam: Pharmacologic

NSAID Tylenol Muscle relaxers: short term Opioids: severe back pain

typical scenario

Pt c/o stiffness, spasm, reduced ROM may be precipitating event erector spinae muscle most often affected

Red flags* Possible Fracture

Recent Trauma MVA or significant fall *osteoporosis risk with less trauma

Aggravates low back pain

Sitting

Acute cervical sprain risks

athletes MVA victims

Herniated discs in neck or back

degree of neuro involvement varies (minor numbness to loss of extremality function) DTRs absent

Diagnostic Tests: X-ray

if suspicion for cancer, infection, or spondylosis (slipped disc) reveal lumbar arthritis (90% of ppl >40 yrs) not routinely obtained

Acute cervical sprain

jammed-neck sensation with localized pain peak pain next day and with neck motion no radiation of pain to the extremities

Red Flags: Cauda Equina Syndrome

nerve roots in the lumbar spine are compressed, cutting off sensation and movement Bladder dysfunction perineal sensory loss anal laxity neuro deficit in lower extremities lower extremity weakness

sciatica

neuroglia along sciatic nerve cause: pressure along lumbosacral nerve root (herniated disc, spinal stenosis, compression fracture) shooting pain from hip-foot leg numbness and weakness

risk factors

older age overactivity overweight -spinal stenosis, scoliosis -disc herniation, lumbosacral strain

Neck Pain

result of abnormalities of the tissues muscles, or bones of the spine -injury, poor posture, prolonged wear and tear -rare: tumors (C6-C7) or infection Pain and stiffness

CT

reveals bony structure information

MRI

reveals soft tissue problems

Lumbosacral Disc Herniation

soft center of a spinal disc pushes through a crack in the tougher exterior casing. after yrs of back pain after repeated damage may or may not cause symptoms L4-L5 L5-S1

Straight Leg Raise Test

test done during a physical examination to determine whether a patient with low back pain has an underlying nerve root sensitivity, often located at L5.