Back and Neck Pain Flashcards
Local pain
Pain localizes to a specific place in the back
Causes: Fractures, tears, stretching of pain-sensitive structures
Referred pain
Pain originates from a visceral organ and is referred to the back
Causes: AAA, pancreatitis, renal calculi, perforated peptic ulcer
Radicular back pain
Sharp, radiating into the dermatomal distribution of a dermatomal distribution of a nerve root. Made worse with any Valsalva maneuver
Causes: Herniated lumbar disc, degenerative joint disease at the intervertebral foramen, epidural disease
Muscle spasms
Painful spasms in the paravertebral muscles. Usually paroxysmal
Causes: Usually of unclear origin
Red flags for possible serious underlying process.
These patients should be imaged
1) Age over 50
2) History of cancer
3) Pain for more than a month
4) No relief even with bedrest
5) Bowel or bladder incontinence
6) Focal leg weakness or numbness
7) Glucocorticoid or IV drug use
8) Current systemic infection
9) Unexplained fever or weight loss
10) Reproducible percussion tenderness over the spine
11) CVA tenderness
L2 lumbosacral radiculopathy
Reflex - none
Sensation - upper anterior thigh
Weakness - iliopsoas
Pain - Anterior thigh
L3 radiculopathy
Reflex - None
Sensation - Anterior knee
Weakness - Iliopsoas, Quads, Hip adductors
Pain - Anterior knee
L4 radiculopathy
Reflex - Patellar
Sensation - Medial calf
Weakness - Quads, Tibialis anterior
Pain - Medial calf
L5 radiculopathy
Reflex - none
Sensation - Dorsomedial surface of foot, lateral calf
Weakness - Peronei, tibialis anterior, extensor hallicus
Pain - Lateral calf, dorsomedial foot, buttocks/posterior thigh
S1 radiculopathy
Reflex - Achilles
Sensation - Plantar and lateral surfaces of the foot
Weakness - Gastrocnemius, Soleus, Gluteus maximus
Pain - Plantar and lateral foot, buttocks/posterior thigh
C5 radiculopathy
Reflex - Biceps
Sensations - Shoulder, thumb
Weakness - Deltoid, biceps
Pain - Medial scapula, lateral arm
C6 radiculopathy
Reflex - Biceps
Sensations - thumb, index finger, radial hand, lateral forearm
Weakness - Biceps, pronator teres
Pain - Lateral forearm, first 2 digits
C7 radiculopathy
Reflex - Triceps
Sensation - Middle digits, posterior forearm
Weakness - triceps, wrist extensors, finger extensors
Pain - Posterior arm and forearm, middle digits
C8 radiculopathy
Reflex - Finger flexors
Sensation - fifth digit, medial hand, medial forearm
Weakness - Intrinsic hand muscles
Pain - Last 2 digits, medial forearm
T1 radiculopathy
Reflex - Finger flexors
Sensation - medial arm, axilla
Weakness - intrinsic hand muscles
Pain - medial arm, axilla
Lumbosacral sprain
Confined to lower back with no radiation or neuro deficits. Paraspinal muscle spasms cause patients to assume unusual postures. Usually post-traumatic
Workup: None needed
Tx: Encourage light exercise and return to normal activity. Consider PT referral. Prescribe NSAIDs or acetaminophen. Use opioids and muscle relaxants carefully
Vertebral fracture
Caused by trauma, osteoporosis or vertebral tumor. Persistent local pain with overlying paraspinal muscle spasm. Neuro deficit from radiculopathy may be present
Workup: Plain radiographs initially. Bone scan or MRI if pathologic fracture from tumor suspected
Tx: Ensure adequate pain control. Ortho consult. May be candidate for kyphoplasty
Lumbar disc disease
Presents with limitation of spine flexion and radiculopathic features. Most common at L4-L5 and L5-S1. Exacerbated by Valsalva
Workup: If no red flags, may manage conservatively for one month. MRI is the best diagnostic test. Note that many patients with no back pain have herniated disks on MRI
Tx: See lumbosacral strain. Surgery indicated for progressive motor weakness, abnormal bowel or bladder function and incapacitating radicular pain with MRI correlation
Spinal stenosis
Caused by a narrowed spinal cord. Back and bilateral leg pain provoked by standing or walking, known as pseudoclaudication. Usually relieved by sitting.
Workup: MRI is most sensitive
Tx: Conservative treatment with NSAIDs, other pain relievers and PT. Surgical management when pain is incapacitating or severe focal deficits develop
Spondylosis
Pain usually caused by osteophytes which may compress nerve roots. Pain centered in the spine increased by motion. associated with limitation of motion
Workup: Plain films will show osteophytes and can suggest whether there is narrowing of the intervertebral foramen. MRI and CT more sensitive
Tx: Conservative treatment with NSAIDs, other pain relievers and PT. Surg when pain is incapacitating or severe focal deficits develop
Neoplasm
Back pain is a common neuro complaint in cancer patients and may herald a diagnosis. The pain is usually constant, dull, unrelieved by rest and worse at night.
Workup: MRI is the most sensitive study for evaluating epidural disease and vertebral mets. Bone scan and CT also play a role.
Tx: Intractable pain from vertebral mets may respond to radiation depending on tumor type. Neuro deficits from epidural disease demand radiation or surgery
Infection
Epidural abscess presents with fever and back pain aggravated by palpation or movement. Vertebral osteomyelitis may not present with fever.
Workup: MRI
Tx: ABx and surgical management are usually combined
