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Low Back Pain – Strains and Sprains
- Split into acute, less than six weeks, and chronic, greater than 12 weeks
- Usually, no cause is found
- Imaging is not recommended for nonspecific back pain for at least four to six weeks
Clinical Presentation
- I twisted my back, and now I can’t move
- Pain in the lower back
- Point tenderness over the low back
- Sciatic pain – pain shooting down my leg
Labs, Studies, and Physical Exam Findings
- Inspection and palpation of the back
- Range of motion
- Straight leg raise, looking for a herniated disc
- Asses L5 and S1 nerve roots looking for a herniated disc
- Imaging only after several weeks of pain or if there is an indication such as a fall or concern of metastatic disease
Treatment
- NSAIDS
- Acetaminophen
- Opioids
- Physical therapy
- Most patients will improve within a few weeks
Herniated disc
- 98% of herniated discs that are symptomatic occur at L4-L5 and L5-S1
- This is a herniation of the nucleus pulposus through the annulus fibrosus
- Causes
- Degeneration of tissue secondary to age
- Trauma
- Repetitive lifting and bending
Clinical Presentation
- Pain radiating from my back down my leg
- Weakness
- Incontinence
- Sexual dysfunction
Labs, Studies, and Physical Exam Findings
- Straight leg test – Dorsiflex the ankle of a patient lying supine. Lift the leg with the knee straight. Attempt to lift the leg until the hip is at 90 degrees. Radiculopathy is a positive sign.
- Crossed straight leg test – Elevate the unaffected leg in the same manner. If symptoms appear in the affected leg this is a positive sign
- Checking L5 nerve root
- Decreased ankle strength
- Decreased strength of great toe dorsiflexion
- Numbness of the medial foot and the webspace between the 1st and 2nd toe
- Checking S1 nerve root
- Numbness of the posterior calf
- Numbness of the lateral foot
- Weakness of plantar flexion
- Achilles reflex
Treatment
- NSAIDS
- Epidural steroid injection
- Physical therapy
- Surgical treatment
- Discectomy
- Anterior cervical discectomy and fusion (ACDF)
Cauda equina syndrome
- “Horsetail”
- This includes
- Lumbar nerve roots 2-5
- Sacral nerve roots 1-5
- Coccygeal nerve
- These nerves innervate the pelvic organs and the lower limbs
- In most adults, the spinal cord ends, and the cauda equina begins at L1-L2
- Causes
- Herniated disc
- Osteoarthritis
- Compression fractures
- Congenital – narrow spinal canal
- Trauma
- Tumor
- Inflammatory conditions
Clinical Presentation
- Saddle anesthesia
- Bowel or bladder incontinence
- Sexual dysfunction
- Pain in the lower extremities
- Paraplegia
Labs, Studies, and Physical Exam Findings
- Paraplegia
- An altered sensation of pain in the lower limbs
- CT
- MRI
Treatment
- Acute onset of cauda equina syndrome is an emergency requiring immediate attention
- Surgical decompression
Spinal Stenosis
- Narrowing of the spinal canal resulting in compression of the spinal cord or nerve roots
- Cervical and lumbar stenosis are far more common than thoracic
- Causes
- Herniated disc
- Osteoarthritis
- Compression fractures
- Congenital – narrow spinal canal
- Trauma
- Tumor
- Inflammatory conditions
Clinical Presentation
- Pain with lying down
- Low back pain
- Gait issues
- Pseudo claudication – the patient has good pulses
- Anesthesia or paresthesia
- Weakness
- Radiculopathy – pain, weakness, or numbness radiating down a particular nerve distribution
- Loss of bowel or bladder function
- Shopping cart sign – relief of symptoms while bending forward and pushing a shopping cart.
Labs, Studies, and Physical Exam Findings
- X-ray
- MRI
- Myelogram
- Electromyogram and nerve conduction
Treatment
- NSAIDS, Tylenol
- Exercise and physical therapy
- Epidural steroid injections
- Lumbar decompression laminectomy
- Remove the bone and ligament overlying the spinal canal
