2. HYHO: SPE 3-3 Flashcards
Describe how often patients come into clinic with non-specific LBP and what is often the course?
>85% of pts that go to clinic have LBP and most improve in few weeks
Because it is not always possible to determine cause and to rule out SERIOUS cases of LBP, ______ is KEY in figuring out cause of LBP
HISTORY; ask about other symptoms!
When taking history for LBP, it is important to ask about _____.
Constitutional symptoms: unintentional WL/fever/sweats, hx of cancer, neurologic sx, injection drugs.
Factors that suggest LBP is due to a systemic disease (5), < 1% have serious systemic etiology
- Hx of cancer
- > 50 YO
- Unexplained WL
- Pain > 1 month; worse at night
- Not respond to previous therapies
Acute, subacute and chronic LBP
- Acute: < 4 weeks
- Subacute: 4-12 weeks
- Chronic: > 12 weeks
_______ is most commonly caused by herniation of intervertebral disc.
Spinal cord or cauda aquina compression
Cord Compression
- _____ = usually FIRST symptom
- _____________ = found in majority of patients when diagnosed
- ___________ = late symptoms
- Pain
- Motor weakness & sensory findings
- Bowel or bladder dysfunction
_________ = strongest risk factor for back pain from bone metastasis
History of cancer
Spinal epidural abscess
- __________\_ = initial symptoms
- Change overtime
- Nonspecific symptoms (fever and malaise)
- Localized BP => radicular pain => neurologic deficits
BP that gradually increases over week => months that MAY/MAY NOT present w fever
Vertebral osteomyelitis
Other etiologies outside of spine that cause LBP
- Pancreatitis
- Nephrolithiasis
- Pyelonephritis
- AAA
- Herpes Zoster
Name the lumbar nerve root
- Blue => L4
- Orange => L5
- Green => S1
L4
- Motor weakess:
- To screen:
- Reflex:
L4
- Motor weakess: extension of quads
- To screen: squat and rise
- Reflex: knee jerk will be diminished
L5
- Motor weakess:
- To screen:
- Reflex:
L5
- Motor weakess: dorsiflex big toe and foot
- To screen: walk on heels
- Reflex: N/A
S1
Motor weakess:
To screen:
Reflex:
S1
Motor weakess: Plantarflex big toe and foot
To screen: walk on toes
Reflex: Diminshed ankle jerk reflex
OSE Sympathetics
- Head/neck (upper ESO)
- Heart
- Lungs
- UGI (lower ESO)
- SI/ascending colon
- Ascending and transverse colon
- Descending and sigmoid colon/rectum
- Adrenal glands
- GU tract + bladder
- Ureter (upper/lower)
- Extremeties (upper/lower)
- Head/neck (upper ESO) = T1-5
- Heart = T1- 6
- Lungs = T1 - 7
- UGI (lower ESO = T5-10
- SI/ascending colon= T9 - 11
- Ascending and transverse colon= = T10 - L2
- Descending and sigmoid colon/rectum = T12- L2
- Adrenal glands = T5 - 10
- GU tract + bladder = T10 - L2
- Ureter (upper/lower) = T10-11/ T12- L2
- Extremeties (upper/lower) = T2-7/ T11 - 12
LBP _____ = no imaging
less than 4 weeks (acute LBP) bc most will improve rapidly
Who should get imaging for LBP?
- Severe or progressive neurologic deficits
- Serious underlying conditions are suspected based on hx and PE
________= emergent MRI and referral to specialist
- Spinal cord/cauda equina compression (new urinary retention/incontinence, new fecal incontinence, saddle anesthesia)
- Progressive and/or severe neurologic deficits (Significant/progressive motor deficits not localized to 1 nerve root)
Imaging?
Radiculopathy due to 1 nerve root or with stable sx due to spinal stenosis
No, unless
- High risk metastic cancer => plain XR + EST or CRP
- Moderate - high risk of infection => MRI
What are “red flag” sx for LPB?
Sx that may ID pts at risk for more dangerous cause of back pain and should get earlier imaging
Red flag sx for LBP
- [Older age, prolong use of corticosteroids, severe trauma and contusion/abrasion] => increase risk of vertebral fracture
- Hx of cancer => increase risk of spinal cancer
Imaging for suspected renoithiasis
- CT of abdomen and pelvis W/O contrast using low-radiation.
- If no CT => US of kidney & bladder + abdominopelvic XR
What to do in PE for LBP? (4)
- Abdominal exam
- Structural exam
- Reflexes
- Strength and sensation
Sx of cauda equina syndrome
- Urinary retention
- Saddle anesthesia
- Bilateral leg weakness
- Bilateral sciatica
Sx of infection
- Fever
- Recent skin/UTI
- Immunosupression
- Use injection drugs
Sx of cancer
- Hx of cancer
- Unexplained WL
- > 50
- Lasts > 1 month
Sx of compression fracture
- > 70 YO
- F
- Corticosteroid use
- Hx of osteoporosis
- Trauma
Sx of lumbar radiculopathy
- Sciatica
- Abnormal neurologic exam
Tx of acute LBP
-
Nonpharmacologic therapy: superficial heat and patient education
- Massage, acupuncture, spinal manipulation
-
If not responsive or prefer meds: short-term (2-4 weeks) NSAIDS/ acetominophen if CI.
- Refractory pain => nonbenzo muscle relaxand
For acute LBP, is bed rest and activity recommended?
- No bed rest
- Keep activity to a minmum; do not refer for XRCISE or PT unless have RF for chronic
What should be included in patient education in LBP?
- Cause
- Prognosis
- Minimal value of diagnostic testing
- Recommendations for activity and work
- When to contact doc
If not adequate relief or CI to other drugs, give = __________
- Opoids (only for 3-7 days) and tramadolol (no longer than 2 weeks)
When should pts with LPB be reassessed?
No improvement after 4 weeks of pharmocotherapy
Predictors of chronic LBP? (5)
- Cannot cope with pain
- Functional impairment
- Poor health
- Psychiatric problem
- Nonorganic signs
