Live Blog: Low Back Pain

Our didactic was done by Dr. Kristin Remus, a clinician educator at BIDMC and one of CCC's faculty preceptors.

Low back pain (LBP) is the second most common cause of disability in US adults. Many people miss work because of LBP. This disease has a 10% population prevalence with LBP for more than 2 weeks prevalent in 14%. Factors associated with LBP are work (exposure to high vibrations such as truckers and jackhammer constructioners), obesity, physical inactivity, arthritis/osteoporosis, age greater than 30, bad posture, and stress or depression.

In acute and chronic LBP, some mechanical causes are dislocation, compression, muscle strain and sprain, herniated disk. Non-mechanical causes are aortic aneurysm, infection, epidural abscess, ectopic pregnancy, diseases of the bone, metastases, and fibromyalgia.

Can we prevent it? In the physical exam check the spinous processes, check the greater trochanter on the hip. The ischial tuberosity and paraspinal muscles are usually tender. Do some maneuvers to see how well someone can bend or move, muscle strength testing in toes and ankle. Also do a neuro exam for numb dermatomes which all end in the feet, check patellas, do the straight leg raise for pain, and test gait such as toe walking and heel walking.

Lasegue's Sign: a straight leg raise physical exam finding. When you stretch the sciatic nerve you can decide if the patient has some sort of LBP. Symptom severity does not correlate well with outcome, so the pain can go away at any time.

Waddell's signs: inappropropriate tenderness superficial or widespread, LBP on axial loading of the head, inconsistent straight leg raise test seated or standing, sensory deficit without nerve root innervation, 3/5 psychological distress.

Discerning what the red flags are will let you know who to look at under an x-ray.

Red flags:

• Urinary retention, stool incontinence
• Neurologic symptoms such as tingling or loss of sensation. 
• People older than 70 often get imaged
• Unexplained weight loss, 
• Prolonged use of corticosteroids, 
• IV drug use, 
• Saddle anesthesia

Patient History:

• Does the patient have a systemic disease? 
• Do they have neurologic compromise or the need for surgery? 
• Do they have social or psychological distress?

Take home points: 

• In the physical exam, be systematic with palpation and inspection.
• Do a dorsi flex and plantar flex for any pain to confirm the straight leg raise test.