Low back pain CIL

Case 1
21yo female with low back pain, sudden,
severe, pain is located on one side, specific
segmental pain worse with activity, relieved
with rest, pain worse with lumbar extension
and pain improves with NSAIDs. Associated
findings: discomfort following heavy lifting.
PE: inability to stand erect, decreased lumbar
extension/backward bending, L1-2 rotated and
sidebent the same way, L5 rotated and
sidebent the same way, increased muscle
tonicity and tenderness over facet joints
 What is the diagnosis?
Lumbar somatic dysfunction
Sacral dysfunciton
Psoas syndrome
Spinal stenosis
 What is the key finding that
differentiates the correct diagnosis
A. Unilateral tenderness over the facet
joints this is what leads you to the
diagnosis
B. Lower lumbar segmental
dysfunction
C. Increased pain with extension
(flexed s/d)
D. Patients age (degenerative things,
prostate cancer)
E. Lack of visceral dysfunction
What is the most likely origin of the
patients pain?
A. Muscle spasm compressing a nerve occurs in
sciatica
B. Muscle splinting
C. Capsular nipping capsule around facet joint of
vertebrae is highly innervated, when the facet
is out of alignment, the capsule gets nipped
b/w the segments, this is the origin of the pain.
D. Age-related anatomical changes patient is not
old, this doesnt make sense
E. Viscero-somatic reflexes
 What technique would be most
appropriate OMT technique to perform
on this patient?
A. Lumbar muscle energy better
because it also treats the muscles and
she is in pain.
B. Lumbar roll wouldnt want to do this
because she is in a lot of pain and there
is a lot of force involved.
C. Prone posterior lumbar counterstrain
D. Anterior lumbar counterstrain
E. Lumbar soft tissue
 Case 2
65yo female presents with persistent
dull aching low back pain. Over the
last 5 years, it has been getting
worse. She has been taking NSAIDs
but they are not as effective as they
once were. She tells you she had
injections in her back about 3 years
ago that worked for a little while.
 The most probable diagnosis for this
patient is:
A. Psoas syndrome
B. Degenerative disc disease no
because the pain would radiate,
would have radiculopathy
C. Spinal stenosis
D. Osteoarthritic joint disease, injections
were facet injections into the synovial
joints
E. Lumbar somatic dysfunction
 To diagnose facet arthropathy one
should:
A. Order labs for inflammatory markers
not specific
B. Order a lumbar x-ray
C. Order lumbar CT
D. Order lumbar MRI would work but
it is very expensive
E. Order lumbar facet injections
usually injected under flouro
If the lumbar facet pain fails medicinal
treatment, other treatments include:
A. Intra-articular steroid/local
anesthetic injections under flouro
B. Radiofrequency ablation to block
joint from all sensory input
C. OMM
D. All of the above
E. A and C
 Case 3
62 yo female presents with
intermittent crampy low back pain
and numbness and tingling with
radiation to the buttock and into the
thigh and legs bilaterally. HPI
reveals the symptoms have
gradually been getting worse.
Walking down hill and standing
seems to make it worse. Sitting and
walking uphill seems to make it
 This patient appears to have
symptoms consistent with:
A. Psoas syndrome
B. Degenerative disc disease
C. Spinal stenosis
D. Prostatitis
E. Renal lithiasis
These symptoms occur due
to:
A. Ligamentum flavum hypertrophy
B. Facet hypertrophy
C. Vertebral body osteophytosis
D. Herniated nucleus pulposis
E. All of the above
 The most consistent abnormal
physical finding in lumbar stenosis is:
A. Low back pain
B. Diminished lumbar extension leaning
back causes the facet joints to
approximate more which narrows the canal
because of this the nerve roots coming out
of the spinal cord are compressed.
C. Loss of lumbar lordosis
D. Positive stoop test
E. Pain with stationary biking
 The gold standard for imaging of
lumbar stenosis is
A. MRI if you find other pathology you
do a ct myelogram or plain
myelogram
B. CT
C. CT myelogram
D. Plain film
E. myelography
 Case 4
49 yo male complains of low back pain for the last 2 days
following being tackled in a football game. The pain is
sudden in onset, described as a spasm, constant, and is
intolerable. He has not been able to sleep well since the
tackle. The patient also notes lumbar spinal muscle
tightness, pain in the low back with radiation to
hip/buttocks, diffuse regional pain, pain worse with any
activity/relieved marginally with rest and NSAIDs.
Associated findings: pain with twisting at the waist
PE: decreased lumbar flexion/forward bending, marked
tenderness in muscle bellies, increased muscle tonicity
and tenderness over costovertebral angle.
What is the most likely diagnosis for
this case?
A. Lumbar somatic dysfunction
B. Psoas spasm
C. Pelvic somatic dysfunction
D. Nephrolithiasis
E. Lumbar sprain/strain traumatic
etiology, not segmentally localized
 You try and position the patient for OMT, but he is in too much pain to
relax for treatment. He is markedly tender to touch all over his low back,
pelvis and sacrum, and unable to be positioned supine or prone. What
would be your next best course of action?

A. Prescribe bed rest with return to clinic (RTC)

in 3 days contraindicated with low back
strain/sprain
B. Prescribe muscle relaxants with RTC in 5
days
C. IM Toradol, Rx for NSAIDs, RTC in 3 days
D. Try to treat him anyway with muscle energy
could be hard to do., counterstrain could
work if you could get him to lay down
E. Order MRI to rule out disc pathology
When he returns in 3 days, his pain is tolerable and
you are able to proceed with a thorough structural
evaluation and treatment. What structure are you
likely to find dysfunctional?
A. Lumbar segment
B. Iliolumbar ligament
C. Psoas
D. Sacrum
E. Pelvis
 Case 5
46 yo obese female presents
complaining of sudden onset of sharp
lumbar pain after feeling a pop in the
back while using her right foot to try
to kick a shovel into hard ground with
the bottom of her foot. The pain is
described as sharp stabbing grade
9/10 with radiation to rt. Buttocks
and thigh just above the knee. Later
it extended to below the knee. Any
 The most probable
diagnosis is?
A. Psoas syndrome
B. Degenerative disc disease
C. Spinal stenosis
D. Osteoarthritic joint disease
E. Lumbar somatic dysfunction
 On PE one would find?
A. Abnormal posture
B. Pain with flexion of the spine
C. Pain with rotation of the spine
D. Pain with getting up from lateral
recumbent position
E. All of the above
The correct terminology for extended bulge with
loss of annular fibers, but disk remains intact is:

A. Disk bulge
B. Disk protrusion
C. Disk extrusion
D. Disk sequestration
E. None of the above
 To initially diagnose DJD through
radiography one should:
A. Order a bone scan
B. Order a lumbar x-ray
C. Order a lumbar CT
D. Order a lumbar MRI
E. Order myelography
 The drug of choice for acute disk
disease is:
A. Ibuprofen anti-inflammatory
B. Hydrocodone/APAP
C. Cyclobenzaprine
D. Acetaminophen
E. diazepam
 Case 6
32 yo male presents with low back pain. He has
been doing some heavy lifting outside at work.
He is concerned because he has developed
cramps and severe pain in the back, nausea, and
vomiting x2, with pain now in the scrotum. He
complains of not being able to get comfortable.
Vitals: BP is elevated at 150/94, pulse is 96,
respirations 16, temp is 99
PE unremarkable except for Lloyds test on the
left
Testicular exam - unremarkable
 The most probably
diagnosis is:
A. Psoas syndrome
B. Degenerative disk disease
C. Spinal stenosis
D. Prostatitis
E. Renal lithiasis
 The most common type of stone
contains:
A. Calcium
B. Uric acid
C. Cystine
D. Ammonium acid urate
E. Xanthine
 The best initial radiographic study
for renal colic is not believed to be a:
A. KUB (kidney, ureter, bladder)
B. Renal ultrasound
C. IVP (intravenous pyelogram)
D. Helical CT without contrast
E. Helical CT with contrast
 Treatment of renal lithiasis that
requires surgery is usually for
stones over :
A. 2mm
B. 4mm
C. 6mm kidney stones and for gall
bladder stones
D. 7mm
E. 8mm
 Case 7
56yo female complains of low back pain. Pain is
sudden in onset, spastic and tolerable. The pain is
located on one side. The patient also notes back
pain radiated to the groin, pain worse with standing
and pain worse with lumbar extension. Associated
findings: guarding posturing
PE: inability to stand erect, tenderness to palpation,
decreased lumbar extension/backward bending,
tenderness along origins and insertions, (+)
Thomas test, anterior tenderpoint 2 inches medial
to ipsilateral ASIS and L1-2 rotated and sidebent
(RxSx). ANO-Genital pelvic exam is unremarkable
 What is the most likely
diagnosis?
A. Lumbar somatic dysfunction
B. Psoas spasm
C. Pelvic somatic dysfunction
D. Nephrolithiasis
E. Spinal stenosis
 What is the differentiating
factor?
A. Radiating to the groin
B. Unilateral
C. Inability to stand erect
D. L2 RrSr
E. (+) Thomas test
 Which of the following best
distinguishes psoas spasm from
psoas syndrome
A. Lower lumbar segmental
dysfunction
B. Contralateral piriformis spasm
C. Upper lumbar non-neutral segment
D. Ipsilateral pelvic shift
E. Unilateral sacral dysfunction
What would be the OMT treatment of
choice for this patient?
A. Lumbar roll
B. Sacral muscle energy
C. Piriformis counterstrain
D. Psoas counterstrain
E. Psoas muscle energy must shut
down neurologic reflex first; chronic
treatment
 What additional education is
important to prevent recurrence
A. Proper lifting technique
B. Strengthening transverse and
oblique abs
C. Postural correction
D. Self-treatment of the tenderpoint
E. Proper stretching technique
F. All of the above
 Last Case
30 y/o male complains of low back
pain. The pain is sudden in onset,
dull and moderate. The patient
cannot localize the focus of his pain
and also notes the radiation to the
buttocks
Dx: sacro-pelvic SD
Most likely sacral diagnosis: L on R
sacral torsion
Treatment: Lumbar FPR, sacral rocking
or lumbar ME, piriformis JSCS