Question about patient with low back pain

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Your patient seems to suffer from chronic back pain - Pain with onset > 3 months
5% of patients with low back pain
85% of costs due to loss of work and compensation
50% have clear structural diagnosis made for cause of their back pain

Your history is non contributory; provide a detailed history and rule out any red flags. These are

Weight loss, fever
History of cancer, exposure to TB, IV drug abuse
Age > 50
Adenopathy
Neurological symptoms

uni/bilateral
urinary retention
saddle anesthesia
Writhing in pain
(visceral/vascular)
Unrelenting pain at rest
(infection/ malignancy)

Do some additional tests for Physical examination briefing of which is as under:

Inspection

Posture
shoulders and pelvis level
normal lordotic/kyphotic curve present
Skin abnormalities
Gait

Palpation

Skin temperature
Bony contours
Soft Tissue contours
Local tenderness

Range of motion

Flexion (> 60 degrees*)
Schober's test
floor-to-finger measurement
Extension (> 25 degrees*)
Lateral Bending (> 25 degrees*)
Rotation
*values for which no disability would be assigned

Neurologic examination

Motor
Sensory
DTRs
Pathologic reflexes
Cord levels (Motor, sensation and reflexes)

Special tests

Straight leg raising With the knee extended and the patient supine or seated. the hip is flexed (with the leg straight). A positive test results in pain ln the sciatic nerve distribution and suggests a disc herniation

Lasegue's test(Bragard's test) Flexion of the affected limb's hip is not painful, but extension of the knee while the hip is flexed is painful. Such pain would indicate sciatica and spinal cord nerve root compression

Cross leg (Well leg) raising

Milgram test A test which usually confirms pathology either inside or outside the spinal cord sheath. The test is performed with the patient supine while both limbs are held straight out with the heels two to three inches from the table for at least 30 seconds. The test increases subarachnoid pressure and is positive when the patient is unable to hold the position for 30 seconds without pain, indicating pathology within or outside the spinal cord sheath, such as a herniated disc.


Valsalva


Pelvic Rock

Gaenslen (Indications: Evaluation for Sacroiliac joint disease
Sacroiliitis in Ankylosing Spondylitis. Technique: Passive Thigh Hyperextension. Patient lies supine. Fix lumbar spine against table (eliminates lordosis). Patient flexes hip and knee on affected side. Patient holds knee with both hands.Examiner hyperextends opposite thigh over side of table. Interpretation: Positive Test.Pain on thigh hyperextension suggests sacroiliitis

Patrick or FABER test Background: FABER Mnemonic
Flexion,ABduction, External Rotation.
Indications: Evaluation for Sacroiliac joint disease
Sacroiliitis in Ankylosing Spondylitis
Technique: External Hip Rotation
Patient lies supine
Knee on affected side flexed to 90 degrees
Foot on affected side rests on opposite knee
Examiner places one hand on opposite iliac crest
Stabilizes pelvis against table
Examiner places one hand on knee of affected side
Examiner externally rotates hip on affected side
Knee pushed laterally and down
Interpretation: Positive Test (Patrick's Sign)
Pain on external hip rotation suggests sacroiliitis

Abdominopelvic examination

Special tests
Nonorganic Back Pain

"Nonorganic signs should form part of a routine preoperative screen to help
identify patients who require detailed psychosocial assessment."
"Waddell's Signs"

3 or more considered clinically significant

Superficial (skin roll) tenderness
Nonanatomic Pain
Axial loading that increases pain
Rotation to 30 degrees that increases pain
Lasegue's test (distracted SLR)
Give-way weakness
Non-radicular sensory changes
Over-reaction


Rule out the Differentials of Back Pain

Musculoskeletal

Multifactorial
"Mechanical"
Degenerative Joint Disease (Facets)
Degenerative Disc Disease
Muscular Strain and Spasm
Better with rest, worse with activity
May have antecedent trauma

Radiculopathy

Herniated Nucleus Pulposis (HNP)
L4-S1 in 95% of cases of radiculopathy
L2-4 in 2-5%
75% of those with cauda equina syndrome have saddle anesthesia
L5 radiculopathy
pain/dysesthesia in posterior thigh and anterolateral leg
foot drop with weakness on dorsiflexion
S1 radiculopathy
pain/dysesthesia in posterior thigh and leg, posterior lateral foot
weak plantarflexion
decreased Achilles reflex

Compression Fracture

Acute, severe onset of focal pain
Elderly, prednisone therapy and SLE predispose
Pain will resolve spontaneously in 3-6 months

Inflammatory Back Disease

Examples
Ankylosing Spondylitis
Reiter's Syndrome
Arthritis of Inflammatory Bowel Disease
Psoriatic Arthritis
Morning stiffness
Symptoms better with activity, worse with rest
Young person (< 40)

Visceral/Vascular

Abdominal Aortic Aneurysm (AAA)
Perforating duodenal/gastric ulcer
Pancreatitis
Endometrial disease
Ovarian disease

Spinal Stenosis

Types
Degenerative (seen in elderly; most common)
congenital
Pseudoclaudication/Neurogenic claudication
Better with flexion of back
Bilateral neurologic deficits
Wide-base gait

Infection

Mycobacterium Tuberculosis (Pott's Disease)
Paravertebral Abscess
Intervertebral discitis or osteomyelitis
Herpes Zoster
Pyelonephritis
Endocarditis

Malignancy

"Primary"
Multiple Myeloma
Lymphoma
Pancreatic
Metastatic
Prostate
Breast
Renal Cell
Thyroid
Lung
Colon

Spondylolisthesis/Spondylolysis

Others

Hip disease
Spondylolisthesis/Spondylolysis
Scoliosis
Leg-length discrepancy
Scheuerman's disease
Fibromyalgia
DIS
Diabetic radiculopathy


Your patient seems to suffer from chronic back pain with posterior element pain. Pain which is worsened by increasing the lumbar lordosis, standing and walking is called posterior element pain. Posterior element pain is eased by maintained forward flexion, sitting, hip flexion ( with or without knee extended). Patients who have structural or postural hyperlordosis, who have facet arthropathy, and who suffer from foraminal stenosis show feature of posterior element pain. Pain from extension and rotation are usually of facet origion. Flexion treatment frequently improve the facet disease, spondylolysis, flexion dysfunction and certain types of derangement. Prescription of hyperextension exercises may make the condition worse. The goal of exercises should be to improve the abdominal strength and flexibility. As the hamstring muscles are often tight, so the stretching exercises for the hamstrings should also be emphasized. Pelvic tilt exercises also help to reduce any postural component causing increased lumbar lordosis. Myofascial release may also play a role in reducing pain from the surrounding soft tissues.

The role of bracing for reducing the pain of acute spondylolysis is controversial. The most commonly prescribed braces are thoracolumosacral spinal orthosis (TLSO) or modified Boston Brace.

The use of modalities can be given. These are used in isolation or in combination therapy according to the experience of the therapist. Superficial heating methods like Infra reds, electrical heating pads, moist heat pads & deep heating methods like Short wave Diathermy, Microwave Diathermy, ultra sound therapy & electrical stimulation like TENS, Interferential, high voltage pulsed current generators and diadynamic currents all can be used accoring to individual choice and case selections.

So advice about the spinal flexion exercises, bicycling and walking on sloped treadmill will improve the condition of patient. Patient should be restricted from the provocative activities that increase pain. Activities and exercises that reduces the extension stress are helpful in reducing pain especially in the acute episodes