Differential Diagnosis of Chronic Low Back Pain James
Differential Diagnosis of Chronic Low Back Pain James J. Lehman, DC, MBA, FACO Associate Professor of Clinical Sciences Director Community Health Clinical Education University of Bridgeport Learning Objective
Identify injured and painful tissues through careful assessment and intelligent use of neuromusculoskeletal testing and document the findings of chronic low back pain. Learning Objective Rule-in and rule-out neuromusculoskeletal
conditions that might present as low back pain. Learning Objectives Implement the scientific method and integrate the use of an evaluation
protocol practiced by evidence-based and patient-centered chiropractic physicians. Opening Statement Diagnosis is the key to
successful treatment! Musculoskeletal Disabilities The leading causes of disability in people in their working years are musculoskeletal conditions.
Russell IJ. A new journal. J Musculoskeletal Pain 1(1):1-7. 1993. Lower Back Pain How do you differentiate the types of tissues that
may be involved with a chief concern of low back pain? Focused History of Low Back Pain
Location Mechanism of injury New condition
Onset Provocative and palliative Quality of pain Referred or radiating pain Severity Timing and treatment Focused Neuromusculoskeletal Examination
Observation/Inspection Palpation Range of motion Special tests/orthopedic tests
Neurological examination 3 part peripheral nervous system exam CNS examination Cranial nerve examination Mental status Neuromusculoskeletal Examination Videos Timothy Conwell, DC, FACO Central Nervous System examination
https://www.youtube.com/watch?v=kZOcz0czWs4 Peripheral Nervous System examination https:// www.youtube.com/watch?v=I7YF4vCBisQ Spine and paraspinal examination https:// www.youtube.com/watch?v=HegByhhb8sI Definition of an Orthopedic Test Most often a provocative maneuver that reproduces the
patients chief concern pain with stretching, contracting, and/or compressing in order to identify the involved tissues. James J. Lehman, DC, FACO
Low Back Pain Case Patient strained lower back unloading a truck, which required lifting heavy boxes, twisting and placing boxes on flats three years ago. Lower back pain persists on a daily basis and increases with bending and twisting. Rest reduces the pain. Medications do not relieve the constant dull
ache or the intermittent sharp, stabbing pains. Low Back Pain Differential Diagnosis Please list 5 differential diagnoses List the physical examination procedures that you would use to rule-in and rule-out your differential diagnoses. Differential Diagnosis
Cramps Knots Spasms Dull ache ODonoghues Maneuver Active lumbar
ROM (general findings) Resisted ROM (strain) Passive ROM (sprain) Myofascial Trigger Point Characteristics
Myofascial Trigger Point Palpation Localized pain with palpation Active trigger point may produce referred pain Myofascial Pain Syndrome
Referred Pain Paresthesias Crawling sensation (formication) Dull or deep ache Myotogenous Myotomal
Joint Pain Zygapophyseal or Facet Joint Sharp pain on motion Constant dull or deep ache Source of chronic low back pain Manchikanti L, et al. Prevalence of facet joint
pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskelet Disord. 2004; 5: 15. Dorsal Ramus of Spinal Nerve Primary division of a posterior ramus of a spinal nerve has three
branches Sclerotogenous Referred Pain Resembles radiating pain but it is a referred deep, dull ache from bone, ligaments and
joints Ivanusic JJ. The evidence for the spinal segmental innervation of bone. Clin Anat. 2007 Nov;20(8):956-60. Scleratogenous or Myofascial
Triggers Diffusely referred and hard to localize Deep and achy quality Kellgren & Feinstein Nerve Pain
Lhermittes Sign Nerve Pain Stabbing or lightning-like pain down spine and any combination of
extremities with flexion or extension Recommended Texts Gluteus Medius: Lumbago Muscle Commonly overlooked
source of referred low back pain Iliopsoas: Hidden Prankster Serves many critically important functions, often causes pain, and
is relatively inaccessible. Iliopsoas: Hidden Prankster Unidentified iliopsoas and quadratus lumborum trigger points are frequently responsible for a failed low back postsurgical
syndrome. Iliopsoas: Hidden Prankster When describing the low back pain they run the hand vertically up and down the spine rather than horizontally.
Quadratus Lumborum Joker of Low Back Pain Severe referred tenderness of the greater trochanter may disrupt sleep. Quadratus Lumborum Joker of Low Back Pain Patient may be barely
able to turn over in bed and unable to bear the pain of standing upright or walking. Quadratus Lumborum Joker of Low Back Pain Coughing or sneezing can be frightfully
painful. Not to be confused with Dejerines and a SOL Quadratus Lumborum Joker of Low Back Pain Imagine the patient waking during the night with pain in the
trochanteric area with a full bladder and unable to walk due to severe low back pain! Quadratus Lumborum Joker of Low Back Pain Spasm of QL causes functional scoliosis, loss
of lumbar lordosis with flattened appearance, and restricted ROM. Flexion and extension may be abolished. Muscle Dysfunction Muscle strain, spasm,
weakness, contractures and trigger points may cause muscle imbalances and pelvic obliquity Winter RB, Pinto WC. Pelvic obliquity. Its causes and its treatment. Spine 1986 Apr;11(3):225-34.
Pelvic Obliquity Anatomical short leg or functional leg length inequality due to iliopsoas, gluteus medius and quadratus lumborum muscle contractures may cause
pelvic obliquity Grill F, et al. Pelvic tilt and leg length discrepancy. Orthopade. 1990 Sep;19(5):244-62 Pelvic Asymmetry Long Sit Test
Long Sit Test https://www.bing.com/videos/search? q=long+sit+test+for+leg+length+discre pancy&&view=detail&mid=FA816DBE6 5ED3C2FE0F2FA816DBE65ED3C2FE0F2
&&FORM=VDRVRV Terry Bemis, et al. Validation of the Long Sitting Test on Subjects with lliosacral Dysfunction. JOSPT January 1987. https://www.jospt.org/doi/pdf/10.251
9/jospt.19220.127.116.116 Superficial Paraspinal Muscles Erector Spinae Trigger points in the erector spinae muscles are a
frequent cause of low back pain. Patients might refer to the pain as lumbago. Superficial Paraspinal Muscles Erector Spinae
Trigger points in the erector spinae muscles may cause entrapment of the dorsal primary rami of the spinal nerves. Deep Paraspinal
Muscles Multifidi Trigger point pain is located at the spinous process of the involved segment or
referred a few segments caudal to the trigger point. Deep Paraspinal Muscles Multifidi
Trigger points in the multifidi may cause articular dysfunction at 2-3 segments. Articular Dysfunction
Multifidi trigger point symptoms mimic lumbar facet and sacroiliac syndromes. Schneider MJ. The traction methods of Cox and Leander: neglected role of the multifidus muscle
in low back pain. Chiropract Techn 3(3) 109-115. 1991. Composite Referred Pain Patterns Z Joint Injection of Hypertonic Saline Solution Case 2 Differential Diagnosis 45 year-old male presents with daily pain in the right
sacroiliac, buttocks, abdominal and inguinal regions, lateral hip and right testicle since a lifting injury 5 years earlier. Palpation reveals pain at the lower thoracic and upper lumbar spinous processes and paraspinal muscles, referred pain to the abdomen and right testicle. Taut bands, painful nodules, localized pain in the multifidi muscles and referred pain to ipsilateral lower lumbar spine and abdomen . Radiographic impression of lower lumbar DDD/DJD
Class Discussion What five differential diagnoses would you select? How do you support them?
Maigne Syndrome Thoracolumbar Junction Syndrome Of 350 patients seen in a back pain clinic, 40% were found to have pain of thoracolumbar origin. Maigne R. - Low back pain of thoracolumbar origin. Arch. Phys. Med. Rehabil. 1980, 61, 389395.
Maigne Syndrome Thoracolumbar Junction Syndrome Neuropathic pain is found in three well described regions and serves as the principal clinical component in diagnosing Lumbar
Dorsal Ramus Syndrome (LDRS). Maigne Syndrome Thoracolumbar Junction Syndrome The patient will not usually have spontaneous pain at the offending spinal level. Pain can be provoked by palpation of the facet joints, or the level can remain veiled, with only the referred pain as evidence of the defect.
Maigne Syndrome Thoracolumbar Junction Syndrome Usually unilateral, bilateral cases have been described... Patients will not have pain radiating below the knee, which is more typical of anterior ramus involvement.
Maigne Syndrome Thoracolumbar Junction Syndrome Radiographic evidence is non-contributory. MRI, CT and myelography are all ineffective at localizing the at-fault level. The typical degenerative changes seen on most images may lead to unnecessary surgery or false diagnosis. The posterior ramus is far removed from
herniating or bulging discs. Maigne Syndrome Thoracolumbar Junction Syndrome Pain relieved by injection of local anesthetic into the correct facet joint. This diagnostic procedure can also be therapeutic; the injection of steroids or radiofrequency denervation of the medial
branch can be added for refractory cases. Maigne Syndrome Thoracolumbar Junction Syndrome Thoracolumbar junction syndrome is particularly responsive to spinal manipulative therapy and no further treatment is
required in most cases as long as it is performed adequately. Soo-Ryu Kim, et al. Thoracolumbar Junction Syndrome Causing Pain around Posterior Iliac Crest: A Case Report. Korean J Fam Med. 2013 Mar; 34(2): 152155.
Thoracolumbar Syndrome A Report of Two Cases Spinal manipulation of the thoracolumbar has been demonstrated effective with relief of a chronic thoracolumbar syndrome.
Proctor D, Dupuis P, Cassidy D. Thoracolumbar syndrome as a cause of low-back pain: a report of two cases. The Journal of the CCA/Volume 29 No. 2/June 1985. Active Learning Task Form groups of 3-5 learners
Select a spokesperson Organize a clinical thought process that would enable you to determine the pain generators with a low back pain patient Describe your neuromusculoskeletal examination process for a patient without organic disease Closing Statement
Diagnosis is the key to successful treatment! References
Scott-Charlton, W. and Roebuck, D.J. The Significance of Posterior Primary Divisions of Spinal Nerves in Pain Syndrome. The Medical Journal of Australia. 1972; 2:945948. Maigne, R. Low back pain of thoracolumbar origin (T11-T12-L1). In: Maigne, R., Second Edition: Diagnosis
and Treatment of Pain of Vertebral Origin. Taylor and Francis Group, 2006:28998. McCall IW, Park WH, OBrien JP. Induced pain referral from posterior lumbar elements in normal subjects. Spine 1979;44416. Marks R. Distribution of pain provoked from lumbar facet joints and related structures during diagnostic spinal infiltration. Pain 1989;39:3740. Fukui, S. Distribution of Referred Pain from the Lumbar Zygapophyseal Joints and Dorsal Rami. The Clinical Journal of Pain 1997:13;303307. Sherrington, C.S., Experiments in Examination of the Peripheral Distribution of the Fibres of the Posterior roots of some Spinal Nerves. Philosophical Transactions of the Royal Society of London, vol. clxxxiv. 1893. Maigne, R. Low Back Pain of Thoracolumbar Origin. Archives of Physical Medicine and Rehabilitation.
1980:61;389395. Soo-Ryu Kim, et al. Thoracolumbar Junction Syndrome Causing Pain around Posterior Iliac Crest: A Case Report. Korean J Fam Med. 2013 Mar; 34(2): 152155. Proctor D, Dupuis P, Cassidy D. Thoracolumbar syndrome as a cause of low-back pain: a report of two cases. The Journal of the CCA/Volume 29 No. 2/June 1985.
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