31. Back pain Flashcards
Defn acute back pain - time frame
<6 weeks
DDX systems that could cause back pain
vascular
visceral
infectious
mechanical
rheumatologic
Modifiable F for dx of sciatica and back apin
smoking
alc abuse
obese
depresion
RAdiculopathy dx
clinical
nerve root irriation secondary to compression leading to affected lumbar/sacral root issues in that distribution (pain, weak, numbness, paresthesia)
Adults -where does SC end?
L1 - then into cauda equina
Compressive lesions ABOVE the cauda equina in the conus medullaris give what kinds of sx?
UMN
Name 8 key hx points for back pain
trauma - rip or tear
assoc chest/abdo pain
hx ca
anticoag use
IVDU
immunocomp status/gc use
hx osteoporosis
hx AAA
pt >50y
night/rest pain = worse
worse with cough/valsalva/lift
unexplained w loss
recent bacterail infection (SSTI, lungs, UTI)
recent GI/gu procedure
failure to improve after 6 week conservative tx
saddel anesthesia
bowel/bladder/sexual dysfunc
Name 8 key PE points for back pain
abnormal vitals
unequal BP in upper extremities
murmur/ao insuff
pulse deficit/circulatory compromise of LE
pulsatile abdo mass
ur retension
ur/stool incontinence
loss of rectal/sphincter tone
sev/progressive neurologic deficit
focal LE weakness
new ataxia/difficulty walking
decreased perianal sens
Extraspinal causes of acute back pain - name 6 from chest
aortic dissection, bacterial endocarditis, pulmonary embolism, pneu- monia, pleural effusion, myocardial infarction
Extraspinal causes of acute back pain - name 6 from abdo
ruptured or expanding aortic aneurysm, esophageal disease, penetrating peptic ulcer disease, pancreatitis, pancreatic cancer, cholelithi- asis (biliary colic), cholecystitis, cholangitis
Extraspinal causes of acute back pain - name 3 from renal
nepholithiasis
perinephric absces
pyelo
Extraspinal causes of acute back pain - name 5 from GU
ovarian torsion or tumor, pelvic inflammatory disease, endo-
metriosis, pregnancy, prostatitis
Extraspinal causes of acute back pain - name 5 from MSK
acute muscle strain, acute ligamentous injury, osteoporo-
sis, spinal curvature (lordosis, kyphosis), osteoid osteoma
Extraspinal causes of acute back pain - name 4 from “other” category
herpes zoster, retroperitoneal hemorrhage, psoas abscess, non-
specific low back pain
Name 10 spinal causes of acute back pain
cauda equina syndrome
spinal epidral abscess/hematoma
vertebral OM
infectious discitis
# (trauma/path)
malignancy
tranverse myeltitis
disc herniation
degen disease (disc/facet)
spondylosis (spinal OA)
isolated sciatica
spinal stenosis
What is myelopathy?
sc injury - compression vs inflamm vs ischemia
Spondylosis defn
nonsp progressive degenerative cahnges (including spinal arthritis) of VB, facet joints, central canal
Disc herniation: how does this occur?
annulus fibosis thins and tears, nucleus pulposis prolapses
What type if disc herniation is mc?
lateral as posterior long ligament does not extend laterally
MC sign and sx of spina l infection
diffuse spine pain
mc sever local spinal tenderness
clasic triad epidural abscess
fever
back pain
focal neuro deficit
only present total 15% cases
RF for epidural abscess - list 5
immunocomp
ivdu
recent bacterial infection
db/chronic illness
recent spinal procedure/trauma
MC spinal infection bugs
staph aureus
also consider other gram neg and +, candida
MC site of spine infection - ?
so why consider MRI?
lumbar
skip lesions common - need at least 3-5 levels above
MC source of spinal tumor?
mets
Common ca causing spinal mets?
lung
prostate
breast
mm
lumphma
What mc causes cauda equina?
disc hern L4-5 or L5/S1
other: abscesses, hematomas, fractures, lumbar spondylosis, and tumors.
Name 5 classic features of cauda equina syndrome
bladder dysfunction (found in ∼90%),
bowel dysfunction (∼50%),
sex- ual dysfunction,
saddle anesthesia (decreased perianal and genitouri- nary sensation, found in 80%),
and unilateral or bilateral radiculopathy (progressively worsened back and lower extremity pain that is worse with recumbent positioning, weakness, and sensory abnormalities like paresthesias, found in ∼96%)
Cauda equina incomplete vs retension pt differences
CES-I patients have urinary issues with reduced bladder sensation and difficulty voiding (decreased desire to void, strained micturition and decreased uri- nary stream). CES-R patients have complete urinary retention with overflow incontinence. This clinical characterization has important prognostic value. The functional status of patients at the time of pre- sentation is predictive of prognosis
Transverse myeltitis: what can this be an initial presentation of?
idio
vs sle, ms, vasculitis
previous viral infections - varicella, herpes, cmv
bacterial previous: tb, lyme, syphilis
Dx transverse myelitits
full spine MRI w and w/o contrast
Neurogenic claudication sx constellation
burning cramping pain in back, mo weakness, reflex changes, pain radiating to buttocks, thighs and legs with assoc paresthesia
common in spinal stenosis
Testing for L4 nerve root
sn/reflex/strength and motor
?screening exam?
medial lower leg and foot down to medial surface great toe
patellar reflex
knee ext/ankle inv and dorsiflexion
squat and rise
Testing for L5 nerve root
sn/reflex/strength and motor
?screening exam?
lateral lower leg, dorsum foot and first web space
no reliable reflex
hip abd, knee flex, foot/ankle ev/inv, great toe dorsiflex (ext hallu longus)
heel walking
Testing for S1 nerve root
sn/reflex/strength and motor
?screening exam?
posterior lower leg, lateral/plantar ft/ankle
achilles reflex
hip ext, knee flex, foot plantar flex
toe walk
3 KEY red flag hx questions for ED population
new urinary retension
saddle anesthesia
anticoag use
L1,l2,l3 examination findings
radiation to the groin or anterior thigh, weakness with hip flexion (iliopsoas), and anterior thigh sensory changes in the corresponding dermatome. A partial knee bend while bearing weight on one leg and then the other indicates normal hip, buttock, and thigh muscle strength. There are no individual reflexes for the L1–3 lumbar levels.
S2-5 findings on exam (if issue with these nerves):
lower sacral levels (S2–5) will have sacral or buttock pain that radiates down the posterior leg or into the perineum and can have dif- ficulties with penile erection (S2–4), abnormal perianal sensation (S3– 5), anal wink (S2–4), rectal tone (S2–5), and bladder function (S2–4).
Straigth leg raise test for which?
Straight leg raise (SLR) test for nerve root compression has a sen- sitivity of 72% to 97% and a specificity of 11% to 66%. In high-risk patients with sciatica or neurologic symptoms the test has a positive predictive value (PPV) of 67% to 89% and a negative predictive value (NPV) of 33% to 57%. To perform this test, the patient is positioned supine, with the legs fully extended. The clinician places one hand under the ankle and the other hand on the knee (to maintain leg exten- sion). With the patient relaxed, the straightened leg is slowly lifted by flexing the leg at the hip until pain is elicited or end range is reached. Each leg is tested separately. A positive test causes or reproduces radic- ular pain below the knee of the affected leg when the leg is elevated between 30 and 70 degrees. Care should be taken that the patient is not actively helping in lifting the leg and that the knee remains straight throughout the examination.
Braggard sign
for sciatica
from straight leg raise: A further positive finding occurs if radicular symptoms are elicited when the leg is then lowered until pain is eased and the ipsilateral ankle is dorsiflexed (Braggard sign). Pain at less than 30 degrees, more than 70 degrees, or with reproduction of pain only in the back, hamstring, or buttock region, DOES NOT constitute a positive test result
Cross over test for radiculopathy
Pain referred to the affected leg when the opposite asymptomatic leg is tested, called a positive crossed-SLR, is highly indicative of nerve root irritation from a herniated disc (specificity, 85% to 100%; sensitivity, 29%).
Waddell’s sign to differentiate true from malingering back pain - DORST?
distraction, overreaction, regional disturbances, simulation tests, and tenderness).
Back pain - when to order an u/s
AAA
non spinal
Back pain - when to order a CT
vertebral #
malalignment
bony fragment in spinal canal
if MRI cannot be done
Back pain - when to order an MRI
for looking at soft tissue
sc
n root
intervertebral disc
Mild to moderate BP - analgesia recommendations
enteral nsaid
no benefit tylenol add
ST pain relief/bridge in severe back pain or consideration in chronic per Rosen’s?
opioids short course
How to discharge patients safely
red flags on when to return - new progressive arm/leg weakness, bowel/bladder dysfunction or saddle anesthesia
ongoing PE, not complete rest
incr work once improving
work note as needed/accomoodations
What is the most likely cause of back pain in a 48-year-old patient with bilateral leg pain and weakness, urinary retention, decreased rectal tone, and saddle anesthesia?
a. Abdominal aortic aneurysm
b. Bone metastasis
c. Epidural abscess
d. Herniated disk
e. Primary bone tumor
d
What percentage of asymptomatic persons less than 60 years old
will have herniated disc findings on MRI? a. 10%
b. 25%
c. 50%
d. 75%
b
Disk herniation with involvement of the L5 nerve root will present with which of the following findings?
a. Decreased or absent ankle jerk
b. Decreased patellar reflex
c. Diminished sensation of the lateral small toe d. Impaired plantar flexion
e. Weakness with extension of the great toe
e
A history of IV drug use increases the risk for which of the follow- ing causes of acute back pain?
a. Abdominal aortic aneurysm
b. Epidural hematoma
c. Malignancy
d. Transverse myelitis
e. Vertebral osteomyelitis
e
A 35-year-old man presents with severe back pain that radiates
down his right leg. He reports that while lifting a heavy box at work 2 weeks ago, he felt a “pop” in his lower back. He has not been able to return to work since the injury occurred. The patient spoke with his lawyer and was told to come directly to the emergency depart- ment to get an magnetic resonance imaging (MRI). He denies hav- ing any other symptoms and reports no significant past medical history. During the physical examination, the patient is asked to lie on his back, with his knees extended. His right leg is elevated and, at 50 degrees, he reports severe pain running down the lateral aspect of his right leg to his foot. The patient is then asked to sit with his knees flexed and legs hanging over the side of the bed. His legs are passively extended, with no production of pain. The remainder of the physical examination is normal. What is the most appropriate next step in managing this patient?
a. Computed tomography (CT) of the lumbar spine b. Discharge home
c. Emergent neurosurgical consultation
d. MRI of the lumbar spine
e. Radiography of the lumbar spine
b
Spinal epidural abscess is most commonly caused by which of the following pathogens?
a. Mycobacteriumtuberculosis
b. Pseudomonas aeruginosa
c. Staphylococcusaureus
d. Staphylococcus epidermidis e. Streptococcus pyogenes
c
