Term
| what generally characterizes pts w/lower back pain (LBP)? |
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Definition
| the majority will be self-limiting, but almost 50% recurrence. almost 80% have chronic pain and 1/3 have undergone surgical intervention. |
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Term
| what is the cornerstone in terms of diagnosing and treating LBP? |
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Definition
| the motion segment, which is divided into the anterior (wt bearing) and posterior (gliding, rotation, sidebending and restricting motion). the motion segment is a three joint complex: 2 facet joints, 1 disc. |
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Term
| what characterizes the nucleus pulposus and annulus (intervertebral disc)? |
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Definition
| the nucleus is mostly water which holds the weight of the body. the annulus is ~90 sheets of fibrocartilaginous lamina which get progressively thicker as you move towards the outside. |
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Term
| where does the intervertebral disc have the most weakness? |
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Definition
| in torsion - particularly in flexion. the posterior lateral portion is weakest structurally. |
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Term
| how can creating more abdominal strength help w/LBP? |
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Definition
| as the abs contract they put tension on the lumbar fascia, which instills an extension moment on the lumbar spine while bending and lifting = less stress on the discs. |
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Term
| what is the annulus innervated by? |
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Definition
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Term
| even if the annulus doesn't herniate, how can it still cause back pain? |
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Definition
| via inflammatory chemical release |
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Term
| what is very important in the overall pathophysiology of lower back pain? |
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Definition
| myofascial involvement. most people undergo minor trauma and possible emotional disturbances, stresses & pressures which can lead to vasoconstriction in the muscle, spasm, hypertonicity = myofascial involvement. |
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Term
| what are the 3 phases of the degenerative process in LBP? |
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Definition
| dysfunction (minor traumas to soft tissue and spine = hypertonicity, spasm, minor restriction in range of motion), unstable (synovial inflammation, laxity within joint segment, hypermobility) and stabilization (osteophyte formation occurs over time, joints become hypertrophic = stenosis). this results in: dysfunction -> herniation -> instability -> lateral nerve entrapment -> one level stenosis -> multilevel spondylosis/stenosis. |
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Term
| what characterizes the role of inflammation in the pathophysiology of LBP? |
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Definition
| there may be a highly antigenic response to discogenic fluid exposed to neural tissue. inflammatory mediators cause swelling of nerves = sensitization and enhancement of pain generation. ongoing inflammation = degenerative spiral. |
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Term
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Definition
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Term
| what do pain locations do all disc pathology subsets share? which is the outlier? where will pain be found on physical exam? (*know this*) |
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Definition
| all disc pathology subsets (annular tear, herniation, and degenerative) share back and buttock pain. disc herniation will also present w/leg pain. on physical exam all disc subsets will show pain w/flexion, and disc herniation may show pain w/a neutral position. |
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Term
| what do pain locations do all posterior element subsets share? where will pain be found on physical exam? (*know this*) |
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Definition
| facet pain and spondylosis will both give back/buttock pain and may give leg pain. all posterior element subsets will present w/pain on extension. |
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Term
| what do pain locations do all stenosis subsets share? where will pain be found on physical exam? (*know this*) |
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Definition
| central/lateral/recess stenosis foraminal stenosis subsets will have pain in back, buttock and leg. central/lateral/recess stenosis will give pain in neutral and extension while foraminal stenosis will give pain in flexion, extension, and neutral. |
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Term
| what do pain locations do all soft tissue subsets share? where will pain be found on physical exam? (*know this*) |
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Definition
| possible in back, buttock, leg. only possible pain on flexion in physical exam. |
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Term
| what are the most common causes of lower back pain? (*know this*) |
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Definition
| non-radicular (85-95%) or pain w/o nerve compression. this can be due to internal disc disruption (>39% = just tears in annulus, dxed by discogram CR), facets (15%), SI joints (12%), soft tissue, and mechanical. |
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Term
| what are the less common causes of lower back pain? (*know this*) |
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Definition
| radicular (5-15%) or pain due to neural irritation or compression such as disc herniation, canal/recess stenosis, osteophytes, spondylolisthesis, and failed back syndrome. |
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Term
| what is disc herniation treatment? (*know this*) |
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Definition
| 85-90% excellent results with conservative (non-surgical) treatment: translaminar or transforaminal (*gold standard*) epidural injection. sx is more risky b/c of scarring risk. |
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