63. Low-back Pain (32%)

Question 1

In a patient with confirmed mechanical low back pain, we should advise the patient what? (3)

Answer 1

• that symptoms can evolve, and ensure adequate follow-up care.
• that the prognosis is positive (i.e., the overwhelming majority of cases will get better).
• discuss exercises and posture strategies to prevent recurrences.

Question 3

Name serious DDX of low-back pain (6)

Answer 3

• Cord Compression
• Infectieux – Discite/abcès péridural/pyélonéphrite
• Cancer métastatique
• Fracture vertébrale
• Rupture d’anévrisme de l’aorte thoracique
• Spondylarthrite

Question 4

When to think about : Cord Compression (3)

Answer 4

• Urinary/Fecal incontinence/retention
• Saddle anesthesia
• Motor weakness/numbness

Question 5

When to think about : Discite/abcès péridural/pyélonéphrite (6)

Answer 5

• Fever
• IV drug use
• severe
• recent surgery
• recent infection
• immunocomprised

Question 6

When to think about : Metastatic Cancer (6)

Answer 6

• Hx
• Weight loss
• Age>50
• Persist
• Night pain
• Pain at rest

Question 7

When to think about : Vertebral fx (4)

Answer 7

Osteoporosis, steroid use, age, trauma

Question 8

When to think about : Spondyloarthritis (10)

Answer 8

• Improvement with exercise
• Pain at night (with improvement upon getting up/activity)
• Insidious onset
• age <40 years
• no improvement at rest
• inflamamtory arthritis
• enthesitis
• uveitis
• psoriasis
• family history

Question 9

Name DDX low-back pain (5)

Answer 9

• Serious : Cord Compression, infeciton, Metastatic Cancer, Vertebral fx, ruptured AAA, spondyloarthritis
• Radicular pain : Intervertebral disc herniation
• Neurogenic claudication : Central spinal canal stenosis
• Non-specific (mechanical)
• Beyond lumbar spine : Gyne, Renal (kidney stones), GI, Hip joint

Question 10

When to suspect Radicular pain ? (4)

Answer 10

• leg pain
• sensory loss
• reduced reflex
• myotomal weakness

Question 11

When to suspect Neurogenic claudication ? (2)

Answer 11

• Bilateral buttock/thigh/leg pain
• pseudoclaudication

Question 12

Describe investigations : Low Back Pain (6)

Answer 12

Rarely needed initially unless (multiple) red flags
* CBC, ESR (tumor, infection)
* Serum Protein Electrophoresis (SPEP) Test (multiple myeloma)
* X-ray (fractures)
* X-ray or CT Sacroiliac joints (ankylosing spondylitis)
* HLA-B27 antigen (spondylarthrite ankylosante)
* MRI (cauda equina)

Question 13

Describe tx Acute or subacute low back pain : Nonpharmacologic tx (3)

Answer 13

• Superficial heat (moderate-quality evidence)
• Massage, acupuncture, or spinal manipulation (low-quality evidence)
• Maintain activity and re-assurance (95% improve in 6 weeks)

Question 14

Describe tx Acute or subacute low back pain : Pharmacologic tx (2)

Answer 14

• Topical NSAIDs
• NSAIDs (eg. ibuprofen 600mg PO QID) or skeletal muscle relaxants (eg. cyclobenzaprine 10mg PO TID) (moderate-quality evidence)

Question 15

Describe tx Chronic low back pain : Nonpharmaco

Answer 15

• Exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence)
• Tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence)

Question 16

Describe tx Chronic low back pain : Pharmaco (3)

Answer 16

• First-line: NSAIDs
• Second-line
• Avoid opioids and cannabinoids unless benefits outweigh risks