APPROACH TO BACK PAIN Flashcards
What are the back pain RED FLAGS
hint (NIFTI)?
Neurological - Neurological: diffuse motor/sensory loss, progressive neurological deficits, cauda equina syndrome (MRI Spine)
Infection: fever, IV drug use, immune suppressed (MRI and Xray)
Fracture: : trauma, osteoporosis risk/ fragility fracture (xray maybe CT)
Tumour: hx of cancer, unexplained weight loss, significant unexpected night pain, severe fatigue (xray and MRI)
Inflammation: chronic low back pain > 3 months, age of onset < 45, morning stiffness > 30 minutes, improves with exercise, disproportionate night pain (rheum consult and guideline)
What are the ssx of CE?
Urinary retention followed by insensible urinary overflow
Unrecognized fecal incontinence
Distinct loss of saddle/perineal sensation
What are the yellow flags of back pain?
And what do they indicate risk for?
- Belief that back pain is harmful or potentially severely disabling.
- Fear and avoidance of activity or movement.
- Tendency to low mood and withdrawal from social interaction.
- Expectation of passive treatment(s) rather than a belief that active participation will help.
YF: psychosocial RF for developing chronic pain
Tx: education and reassurance to reduce chronicity
What are the 4 main patterns or DDx for BP?
- Disc pain (back/buttock dom.)
- Facet joint pain (back/buttock dom. intermittent with extension)
- Compressed nerve pain (Leg dominant - all movements hurt, if improved with rest sgx tx less likely)
- Symptomatic Spinal Stenosis (leg dominant/intermittent/worse with walking/stand)
If no pattern Id’d then likely non-mechanical BP
What Back pain physical exam would you do to ID radicular pain?
SLR- positive with reproduction of leg pain and possible abn neuro
What are the surgical referral criteria for BP?
Failure to respond to evidence based compliant conservative care of at least 12 weeks
Unbearable constant leg dominant pain
Worsening nerve irritation tests (SLR or femoral nerve stretch)
Expanding motor, sensory or reflex deficits
Recurrent disabling sciatica
Disabling neurogenic claudication
What are the BP physical exam minimum requirements?
Standing:
1. Movement in flexion
2. Movement in extension
Sitting:
3. Patellor reflex (L3-4)
4. Great toe ext/power (L5)
5. Great toe Flexion/power (S1)
6. Plantar response - upper motor test
Lying:
1. Passive SLR
2. Saddle sensation (S2,3,4
HAVE TO DO FULL NEURO EXAM AND PEDAL PULSES
What does the femoral nerve stretch test?
L3-4
upper lumbar radiculopathy
What are treatments for disc pain? Recommended fu?
Tylenol, Nsaids, exercise, physio
fu 2-4 weeks if physio and PRN’s needed
How do you manage Facet joint pain?
Tylenol and nsaids, physio, exercise
fu 2-4 weeks
PRN if better in office
Management of Compressed nerve pain?
May rq opioids if tyl/nsaids not effective
change positions frequently
2 week fu for pain mng and neuro review
may need sgx intervention after initial trials/if any worrying ssx occcur
Symptomatic Spinal stenosis (neurogenic claudication) Tx?
Tylenol, nsaids, rest in flexion, use support for walking, sit breaks.
6-12 wk fu for ssx mng and fxn impact assess
List 4 options for mng for Chronic Low Back Pain
What mng has no evidence and/or more harms?
- Exercise
- Spinal manipulation (lumbar)
- Oral NSAIDS
- SNRI’s
What options have increased harms and/or no benefit:
1. Corticosteroid injxn
2. Opioids
3. Acupuncture (unlcear)
4. Rubefacient (capsaicin)
List 10 non pharm management of back pain
Heat
Massage
Spinal manipulation
Yoga
CBT
MBSR
Operant therapy
Accupuncture
Multidisciplinary referral
Core exercises
Less bed rest
What does L1/2 do
Hip flexion
