Intense Low Back Agony.


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Know the Guidelines for Imaging of the spine with intense low back torment. ... Intense agony symptomatic treatment for 4 weeks, re-assess. Picture if torment proceeds. ...
Transcripts
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Intense Low Back Pain Richard W. Kendall, DO. Colleague Professor Physical Medicine & Rehabilitation

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Outline Introduction/Epidemiology. Most Important address!! Life structures/Pain generators Diagnosis Treatment

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Course Objectives Know the RED FLAGS in history taking. Know the Pain Generators of the Lumbar spine Know the Guidelines for Imaging of the spine with intense low back agony. Know the general rules to restoration.

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Epidemiology of Back Pain Who gets it? 60-90% lifetime predominance. 80-90% have repetitive scene. What is the Natural history? 80-90% determines in 1 month. 20-30% stays "endless" 5-10% "debilitating"

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Anatomy 5 lumbar vertebra Transitional portions Components Body Pedicles Facets Lamina Spinous and transverse procedures

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Typical Vertebra

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Vertebral Body End-plate connection Tall (L1).. Wide (L5) L3 Square

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Posterior Elements Spinous Process Lamina Pedicle Transverse procedure

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Lumbar Intervertebral Disk Annulus Fibrosis Dense connective tissue, joined network Outer 1/3 innervated from sinuvertebral nerve and dark rami communicans. Concentric layers connecting to end plates Nucleus pulposus 80-90% water, mucuopolysaccharide, collagen.

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*From Caliet, " Low Back Pain Syndarome", fourth Ed.

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Zygopophyseal Joints Joint Capsule Meniscoid 10% wt bearing Sagital plane L1 45° introduction L5.

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Lumbar tendons ALL PLL Ligamentum flavum Facet cases Interspinous tendons Supraspinous tendons

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Muscle Layers Deep Multifidus, Quadratus lumborum Iliocostalis, longissimus, (Erector s.) Superficial Thoracolumbar belt Lattisimus dorsi

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Nerves and Vessels Neural Foramen Spinal Nerve Dorsal Root ganglion Relationships

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Pain Generators Annulus Fibrosis (external 1/3 just?) Periosteum Neural Membranes (Anterior Dura) Ligaments/Z-joint cases Muscles.

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Diagnostic Pain-area (radiation), subjective, what exacerbates torment better/. Neurologic Symptoms Paresthesias. Bladder/Bowel maintenance or incontinence. Shortcoming.

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Diagnostic History: RED FLAGS Trauma, Age >50, Hx of CA, Unexplained wt misfortune, fever or immunnosupression, IV Drug use, Neurologic shortage.

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Examination Range of Motion (record range and torment) Flexion-40 ° Extension-15° Lateral twisting 30° Rotation-45°

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Neurologic Examination I Strength tests L1, L2-Hip flexion (Psoas, rectus femoris) L2,3,4 – Knee expansion (Quads) L2,3,4 - Hip (adductors and gracilis) L5 – lower leg/toe dorsiflexion (subterranean insect. Tibialis, EHL) L5– Hip abductors (gluteus medius, TFL) S1-lower leg plantarflexion (gastroc/soleus) S1– Hip extensors (Gluteus max., Hamstrings)

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Neurological examination II Reflexes L2,3,4-Quads L5-Medial hamstring S1-Achilles Sensation Pin prick-essentially spinothalamic tract Vibration/position sense-dorsal sections Vibration tried with 256cps fork! Position on 3-4 th digit

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Provocative Maneuvers Straight Leg Raise (prostrate or situated) For L5-S2 radicular manifestations Femoral Stretch For L2-4 radicular side effects FABER\'s test For SI joint, hip joint, lumbar z-joint side effects

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Provocative Manuvers Seated SLR (Slump Test) Standing Femoral Stretch

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Imaging or Not? Low yield without RED FLAGS present. "Irregular" discoveries in Asymptomatic. Jarvik-LAIDback study. Mental. Nervousness, dread shirking conceivably offer assistance? Despondency "there must be something incorrectly"

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Guidelines for Imaging NO RED FLAGS! Intense agony symptomatic treatment for 4 weeks, re-assess. Picture if torment proceeds. AHCPR Guidelines for Acute LBP. Sub intense agony Pain for >4wks. Fizzled symptomatic treatment. Picture. Endless torment none, unless changes in sx\'s Chronic irregular TX as intense patients

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Treatments

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Medications NSAID\'s-calming, gentle agony help. Tylenol-gentle moderate torment alleviation. Opiates moderate to extreme torment. (fall flat above). Anticonvulsants-neurogenic torment. TCA\'s-neurogenic side effects, paresthesias. Muscle relaxants-intense fit.

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General Therapy Guidelines Pain Control (symptomatic TX.). Tissue damage (physiologic TX.) Motion in without pain range. Reestablish Full torment unfenced of movement. Center CONTROL for Neutral spine. Reestablish Muscle ENDURANCE . Reestablish Functional developments.

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Therapies Bed Rest. Under 2 days. ROM. Lower furthest point, multifidus, lats. Center reinforcing. Transversus Ab., quadratus, multifidus, glutes. Multiplanar works out.

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Modalities Thermal (hot/frosty) Ultrasound Electrical Stimulation (NMES) TENS (transcutaneous electrical neurostim.) Bracing

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Injections Epidural methodology Helpful in radicular agony and stenosis Z-joint Blocks Short-term alleviation for encouraging treatment. Average branch squares radiofrequency sores.

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Who needs Surgery? Precarious Spine Acute breaks with Neurologic shortage. Extreme Stenosis After disappointment of forceful non-agent tx. Tumor? Dynamic Neurologic shortage

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