Low Back Pain

Low Back Pain

What is the location of the pain? Is it upper, middle or lower back? Left or right side? What is the duration of the pain or how long ago did it start? Is it getting worse or better? Does the pain radiate? Pain that radiates below the knee- more consistent with sciatica; pain around the buttock- more consistent with lumbar strain. What is the severity of the pain? Use a pain scale of 1 to 10 to make the severity somewhat more objective. Intensity of the pain. What is the quality of the pain? Is it achy, or sharp, or dull, or throbbing? Is the pain constant or intermittent? If intermittent, how often does it occur? Is it present at night or at rest? Are there associated symptoms (such as fever, weight loss, weakness, numbness, tingling)? Are there aggravating or alleviating factors? Aggravating circumstances (active vs. passive motion, day vs. night). Valsalva can increase pain from a herniated disk. Alleviating circumstances (medication, positioning-sitting, lying, standing). What has the patient tried to relieve the problem (what worked, what didn’t). Any history of similar problems? Low Back Pain

2. Pertinent past history. Recent illnesses, history of recent trauma or injury, patient’s occupation, previous history of back injury, history of back surgery, cancer, or DM. (Fatigue is a nonspecific finding which may not help you to narrow your differential diagnosis.) 3. Review of systems. In order to narrow your differential diagnosis for the patient’s problem, a review of systems, focused on pertinent positives and negatives is important.

Neurologic symptoms: saddle anesthesia, lower extremity numbness, tingling, muscle weakness particularly in the lower extremities, fecal incontinence Urinary symptoms: urinary incontinence, urinary retention, hesitancy, frequency, dysuria Gastrointestinal symptoms: nausea, vomiting, hematemesis, hematochezia, constipation, diarrhea, acid reflux symptoms Constitutional symptoms: fever, unexplained weight loss Low Back Pain

4. Current medications and allergies

Approach to the Physical Exam for Back Pain

Perform the back exam systematically in sequential order with the patient: 1. Standing 2. Sitting 3. Supine

Physical Exam for Back Pain – Standing

Throughout the whole exam make certain to note how your patient is sitting, standing, and walking in general, asking yourself, “What is his degree of impairment?” and “How uncomfortable is he?” I. Inspection: Look at posture, contour and symmetry. Also inspect overlying skin to check for any lesions or abnormalities. Low Back Pain

Check for lordosis Check for kyphosis Check for scoliosis

Slight scoliosis may be more easily visualized during lumbar flexion. This is performed by having the patient stand with their feet and hands together, like they are about to dive off a diving board, bending forward toward their toes. Look out across the back to see if the shoulders are level. II. Palpation: Check for any tenderness, tightness, rope-like tension, or inflammation in the paraspinous muscles or tenderness

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over bony prominences. This procedure checks for muscle spasm, vertebral fracture, or infection. III. Range of Motion (ROM): Low Back Pain

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Lumbar Flexion (normal is 90 degrees): This is the best measure of spine mobility. Restriction and pain during flexion are suggestive of herniation, osteoarthritis, or muscle spasm. Lumbar Extension (normal is 15 degrees): Pain with extension is suggestive of degenerative disease or spinal stenosis. Lateral motion (normal is 45 degrees): Most patients should be able to touch the proximal fibular head of the knee. Pain on the same side as bending is suggestive of bone pathology, such as osteoarthritis or neural compression. Pain on the opposite side of bending is suggestive of a muscle strain. Range of motion may be varied due to the patient’s age and body habitus Low Back Pain

IV. Gait: Ask the patient to walk on heels and toes. Expect normal gait, even with disc herniation. Difficulty with heel walk is associated with L5 disc herniation Difficulty with toe walk is associated with S1 disc herniation

V. Stoop Test: Have the patient go from a standing to squatting position. In patients with central spinal stenosis, squatting will reduce the pain. However, asking the patient to run is not part of a back exam and may cause discomfort to the patient who is already in pain.

Physical Exam for Back Pain – Seated Position

Overview of the Neurologic Exam

Deep Tendon Reflexes

Grading Reflexes: 0 No evidence of contraction 1+ Decreased, but still present (hyporeflexic) 2+ Normal 3+ Increased (hyper-reflexic) 4+ Clonus: Repetitive shortening of the muscle after a single stimulation Decreased patella reflex implies nerve impingement at the L3-L4 level. Decreased Achilles reflex implies nerve impingement of S1 levels. Hyper-reflexia is a sign of upper-motor neuron syndrome associated with spinal cord compression. Muscle Strength Low Back Pain

Rating Scale: 0/5 No movement 1/5 Barest flicker of movement of the muscle, though not enough to move the structure to which it’s attached. 2/5 Voluntary movement, which is not sufficient to overcome the force of gravity. For example, the patient would be able to slide their hand across a table but not lift it from the surface. 3/5 Voluntary movement capable of overcoming gravity, but not any applied resistance. For example, the patient could raise their hand off a table, but not if any additional resistance were applied. 4/5 Voluntary movement capable of overcoming “some” resistance 5/5 Normal strength i. Hip Flexion (L 2, 3, 4): Ask the patient to lift his thigh while you push down on his thigh ii. Hip Abduction (L 4, 5, S1): Ask the patient to push his legs apart while you push them together iii. Hip Adduction (L 2, 3, 4): Ask the patient to push his legs together while you push them apart iv. Knee Extension (L 2, 3, 4): Ask the patient to extend their knee while you push it down. v. Knee Flexion (L 5, S1, S2): Ask the patient to flex his knee while you push against it. vi. Ankle Dorsiflexion (L 4, 5): Ask the patient to point his foot up while you push it down. vii. Ankle Plantar Flexion (S 1, S 2): Ask the patient to point his foot down while you push it up. Decreased strength implies nerve impingement of the associated nerve in parenthesis. Sensation

Test for sharp and light touch along dermatomal distribution, great toe (L5), lateral malleolus, and posteriolateral foot (S1) Nerve Root Impingement Syndromes Low Back Pain

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