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For further information, see CMDT Part 43-03: Spine Problems
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Essentials of Diagnosis
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Nerve root impingement is suspected when pain is leg-dominant rather than back-dominant
Alarming symptoms include unexplained weight loss, failure to improve with treatment, severe pain for > 6 weeks, and night or rest pain
Cauda equina syndrome is an emergency; it often presents with bowel or bladder symptoms (or both)
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General Considerations
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Low back pain is the condition associated with the highest years lived with disability
Cause is often multifactorial, making the exact cause difficult to diagnose
There are usually degenerative changes in the lumbar spine involving the discs, facet joints, and vertebral endplates (Modic changes)
The sacroiliac joint, muscles, and tendons also can cause pain
Remains the number one cause of disability globally; second most common cause for primary care visits
Annual prevalence is 15–45%
Annual health care spending in the United States for low back and neck pain is estimated to be $87.6 billion
Associated with most years lived with disability
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Aggravating factors of flexion and prolonged sitting suggest anterior spine disc problems
Aggravating factors of extension suggests facet joint, stenosis, or sacroiliac joint problems
Alarming symptoms for back pain caused by cancer include
Alarming symptoms for infection include
Fever
Pain at rest
Recent infection (urinary tract infection, cellulitis, pneumonia)
History of immunocompromise or injection drug use
Cauda equina syndrome is suggested by
Urinary retention or incontinence
Saddle anesthesia
Decreased anal sphincter tone or fecal incontinence
Bilateral lower extremity weakness
Progressive neurologic deficits
Risk factors for back pain due to vertebral fracture include
Most patients with persistent low back pain have co-occurring areas of pain, especially
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Can be conducted with the patient in different positions: standing, sitting, supine, or prone
In the standing position,
Observe the patient's posture for spinal asymmetries such as scoliosis, thoracic kyphosis, and lumbar hyperlordosis
The active range of motion of the lumbar spine can be assessed; common directions include flexion, extension, rotation, and lateral bending
The one-leg standing extension test can be used to assess for pain
In the sitting position,
Motor strength, reflexes, and sensation can be tested (Table 43–2)
Major muscles in the lower extremities are assessed for weakness by eliciting a resisted isometric contraction for about 5 seconds
Comparing the strength bilaterally to ...