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CDM II > Back pain > Flashcards

Back pain Flashcards

1
Q

Do any of these trends ↓ disability:
↑ utilization of imaging studies
↑ incidence of surgery
↑ use of injections
↑ prescription of opioids
↑costs for LBP

A

Nope

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2
Q

LBP is the __ MC reason for office visits

A

5th

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3
Q

What is the MC reason for neurosurgeon or ortho consult?

A

LBP

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4
Q

LBP not attributed to spec dz/spinal pathology

A

Nonspecific LBP
85% of LBP in PC

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5
Q

What age groups does LBP happen to?
Peak?
MCC of activity decrease in pts <__

A

All ages
55-64yo
45y

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6
Q

t/f: you can give a pt a specific dx without evidence to PROVE it

A

false. this is misleading

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7
Q

There is more disability from LBP than 3 other conditions combined

A

CA
Heart dz
CVA

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8
Q

What are the 7 conditions that MUST be r/o?

A

*ankylosing spondylitis
*compression fracture
*symptomatic herniated disc
*Spinal stenosis
*Cancer
*Cauda equina syndrome
*spinal infection ie osteomyelitis

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9
Q

What are the 2 main conditions that you CAN NOT miss

A

Cauda equina
Spinal infect

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10
Q

Peak age of LBP

A

55-64

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11
Q

2 main goals for LBP mgmt

A

PREVENTION OF DISABILITY
Find the small % of pts w/emergent cause of LBP

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12
Q

LBP:
Acute
Subacute
Chronic

A

<4wks
4-12wks
>12wks

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13
Q

Should pts w/LBP and psychosocail factors be on antidepressants?

A

YES

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14
Q

Risk factors for development of CHRONIC LBP

A

*Psychosocial factors are the strongest predictor
* Congenital spine abnormalities
* Smoking
* Occupation
* Prior episode of LBP
* Physical unfitness
* ↑ age

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15
Q

t/f: hx of same LBP ↑ risk for future episodes

A

truee

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16
Q

Red flags for LBP and Acronym

A

TUNAFISH

Trauma
Unexp. wt loss
Neurologic
Age >50

Fever
IVDU (osteomyelitis)
Steroid use (fx)
Hx of CA
(metastatic until proven otherwise)

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17
Q

H&P besides OLDCAARTS

A

*Prior h/o same?
*What work-up did you have?
*What helped the most? do it again
*Is this episode different? Red flag?
*History of IVDU? Ask them!
*Any systemic infect c/o? Fever, body aches, FLS
*Loss bowel/bladder control OR urinary retention
*Chiropractic manipulation? *vertebral a. dissect until proven not

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18
Q

2 q’s to ask before doing a full work-up

A

Do I think there is there a systemic cause?
Any neurological cause requiring surgery intervention?

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19
Q

Serious Systemic Causes (4)

A

Cancer
Spinal Infection
Compression Fx
Ankylosing Spondylitis

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20
Q

Serious Neurologic causes
req surgery intervention (3)

A

Lumbar disc herniation (and acute), Cauda Equina Syndrome
Spinal Stenosis

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21
Q

__% of LBP CA pts are >50y

A

80

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22
Q

T/F: A LBP pt with h/o CA w/LBP has metastatic dz until proven not

A

yus

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23
Q

what are the 3 CA that met to bone/spine

A

“LBP”
Lung, Breast, Prostate

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24
Q

spianl CA w/u:

A

CBC
plain film
direct to possible source

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25
Q

is night pain a finding in spinal CA?

A

yup, so is:
unexplained wt loss,
pn >1mo
pn unrelieved w/rest,
failure to improve with conservative tx

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26
Q

____ _____ ____ is one of the top 5 reasons we get sued

A

Spinal epidural abscess

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27
Q

Spinal infections
__% from source
__% spontaneous.
What are the common sources?

A

40% source
(UTI, indwelling catherters= foley & picc line, skin infection=cellulitis, IVDU*)

60% spontaneous

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28
Q

t/f: fever is sensitive for spinal infect

A

false. 40%

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29
Q

t/f: spinal tenderness is sensitive for spinal infection

A

true. 86%

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30
Q

Sources for Spinal infection (MC?)

A

IVDU!!!
UTI
indwelling catheters (picc line, foley) skin infect (cellulitis, abscess)

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31
Q

60% of spinal abscess’ are ______

A

spontaneous

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32
Q

If ESR (+) in spinal infect pt
what is study of choice?

A

**MRI WWo

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33
Q

Spinal abscess workup

A

ESR
UA, CBC, Bx Lactate

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34
Q

What is the most sensitive & specific lab for spinal infection?
What do we do if it’s (+)

A

**ESR
→EMERGENT MRI Wwo

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35
Q

Compression fx MC occur in pts w/____
__% will be atraumatic

A

OP
30%

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36
Q

if a pt is on corticosteroids long term, LBP is ___ until proven otherwise

A

Compression fx

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37
Q

Pt profile for compression fx

A

caucasian
female
>70

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38
Q

Workup for compression fx. 1st step?

A

Xray

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39
Q

Will XRay r/o compression fx?

A

no

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40
Q

compression fx: if plain film is (-), what do you do?

A

**CT wo (XRT doen’t r/o)

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41
Q

Do Kyphoplasty & Vertebroplasty result in loss of ht?
When is the best time to implement these tx?

A

yes
Acutely.
not great outcomes overall, but better acutely.

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42
Q

Do Kyphoplasty & vertebroplasty have good outcomes?

A

no

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43
Q

what are the 5 unspecific signs of Ankylosing Spondylitis
specificity if someone has 4/5?

A

“O-PIMP cane”
Onset pn >40yo
Progressive, slow pain
Imrove w/exerice
Morning stiffness
Pain >3mo

85% spec w/4/5

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44
Q

Is AS rare?

A

yes. even (+) screening only 16/367 pts actually have dz

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45
Q

Pt profile ankylosing spondylitis

A

Caucasian
Male
>40

46
Q

Cornerstone finding of ankylosing spondylitis

A

↓ flexion

47
Q

Workup of A.S.
1. __ is (+) in 95% of cases
2. ___ and ___ x-ray
3. ____ and ______ SIJ
4. Bony _____
5. What sign?

A
  1. HLA-B27
  2. Lumbar & Pelvic XRT
  3. Bilateral
  4. Sclerosis
  5. Bamboo sign***
48
Q

A.S
Bilateral or unilateral pain?

A

Bilateral

49
Q

Spinal Stenosis
Bilateral or Unilateral pain?

A

Bilateral

50
Q

Lumbar disc herniation
Bilateral or Unilateral pain?

A

Unilateral

51
Q

What comes first in LDH
Leg pain or back pain?

A

Leg pain

52
Q

LDH: Most h/o recurrent ____ prior to ______.

A

LBP
Sciatica

53
Q

___% of pts w/clinically important disc herniations have sciatica.
What % need surgery?

A

95%

2%

54
Q

peak age lumbar disc herniation

A

30-55

55
Q

what test is most sensitive for LDH?
what spinal level?

A

SLR
L5/S1

56
Q

what 2 Special tests together are specific and sensitive for L.D.H

A

SLR AND CLR

57
Q

What is more concerning?
SLR w/pain
SLR w/ leg droop, ↓ dermatome sensation or other radicular sx (numbness)

A

duh

58
Q

3 L.D.H findings indicative of Neuro compromise requiring surgery

A

ankle dorsiflexion weakness
great toe extensor weakness
↓ pinprick sensation

59
Q

2 PE findings in combo that point to LDH in need of surg (found in 90% of pts who have surgical herniation)

A

impaired ankle reflex
+ weak dorsiflexion

60
Q

What % of L.D.H is asx?

A

20-30%

61
Q

T/F: asx anatomic disc herniation
need further w/u, tx, or referral

A

nope, no ya dont

62
Q

Study of choice for LDH to r/o surgical need?

A

MRI

63
Q

when to get an MRI w/ LDH

A

Sig PE findings
Pain or sx >6wks

64
Q

Is spinal stenosis unilateral or bilateral LBP?

A

BILATERAL

65
Q

How do we differentiate from PVD?

A

***check pulses

66
Q

What is neurogenic claudication?
When does it occur?

A

pn in legs from neuro deficits
occurs after stand/walk

67
Q

Avg age of spinal stenois
How many years of Sx?

A

55 w/4+ yrs of sx

68
Q

3 Key findings of back pain with spinal stenosis

A

*intermittent Back pain slowly progresses to constant pain
*leg “stiffness” or pain
* Pain not provoked by bike riding

69
Q

Cornerstone of Spinal stenosis pain

A

↑ extension

“shopping cart people”

70
Q

Imaging studies of Spinal Stenosis

A

L/S XRT
MRI (or CT w/o)

71
Q

How to Dx Spinal stenosis

A

MRI or CT w/o of L/S

72
Q

what is cauda equina?

A

Massive midline disc herniation → spinal cord compression
EMERGENCY!

73
Q

Early finding of C.E.S? found in __% of cases

A

URINARY RETENTION

74
Q

Loss of bowel/bladder is early or late finding?
Sensitive?

A

LATE but SENSITIVE

75
Q

The most important finding in CES
Found in what % of cases?

A

Urinary retention
90%

76
Q

Where can there be anesthesia in C.E.S?

A

“PP-B”
Posterior-superior thigh
Perianal
Buttox

77
Q

T/F: ↓ rectal tone is common in C.E.S?

A

yup 60-80%

78
Q

3 Common PE /Special test findings in C.E.S?

A

Sciatica
SLR+
Sensory/Motor deficits

79
Q

2 emergent studies/consults you must do w/C.E.S?

A

MRI
Neurosurg consult

80
Q

Should you not take a PCP txfr to ER seriously?

A

HELL NO

81
Q

Should you change other provider’s tx plans?

A

HELL NO

82
Q

T/F: If a good H&P does not yield any concerns for the 7 high-risk processes, no additional work-up is indicated for LBP?

A

sounds good

83
Q

T/F: No imaging or other diagnostic tests are needed initially in a pt w/ nonspecific LBP

A

True

84
Q

When should you obtain spinal imaging (6)?
When should you consider MRI?

A

*High risk for vertebral compression fx
*Suspect infection
*Suspect cauda equina
*Presence of progressive/severe neuro deficits
*Risk factors for CA
- If age only risk factor, consider a time-limited (1mo) trial of therapy
*Suspected radiculopathy or spinal stenosis

CONSIDER MRI:
*in the absence of severe/progressive neurologic sx with no improvement after >6wks

85
Q

What is the most helpful lab for LBP?

A

ESR

86
Q

Initial work-up of Imaging: ____ and Lab: ___ is sufficient in the majority of LBP pts

A

Plain films
ESR

87
Q

T/F: if a pt has 10/10 LBP, it is infectious or neurologic.

A

no, it can still be MSK

88
Q

Pain evaluation is helpful for activity ____ not activity ____.

A

Modification
Limitation

89
Q

Where to refer LBP (4)

A
  • Need for urgent or emergent evaluation →ER
  • PT → Earlier better
  • Neurosurg → unsure of dx/ dx made in which an intervention may be deemed helpful or necessary
  • Pain Management
90
Q

4 active LBP therapies

A

Physical therapy
Massage therapy
Acupuncture
Manipulation

91
Q

Main 2 points of active LBP therapies

A

Initiate aggressively & early

92
Q

EBM Tx of LBP:
emphasis on ____ not ____ therapies

A

Active, not passive

93
Q

Bed rest for LBP?

A

Hell no

94
Q

LBP Tx:
Combine __ with ___ therapies

A

Active w/ pharm

95
Q

first line Rx for LBP?
Which is superior?

A

NSAIDS /APAP

they are the same

96
Q

Second line tx for LBP that are controversial (2)

A
  • Muscle relaxers
  • not great, just makes pt not care
  • Corticosteroids
  • highly debated, gen not recommended
97
Q

Second line tx for LBP that are not controversial (4)

A

*Antidepressants
- psychosocial factors
*Topical Medications
- Voltaren Gel topical Ibuprofen
- Lidocaine patches for focal pain
*Trigger Point injection
- Marcaine
*Nerve pain
- Gabapentin- nerve pain, not spasm
- Lyrica

98
Q

Describe Nerve pain

A

shooting, burning

99
Q

Greatest benefit timeline for m. relaxers?

A

1-2kwks
stop after 2-4wks if not working

100
Q

t/f: you should use corticostroids for radicular pain?

A

you can
medrol dose pack x1 for sciatica

101
Q

T/F: benzos are m. relaxers

A

yes benzos are m relaxers

102
Q

Which benzo can you use for LBP & in which setting?

A

Can use valium 1x if in ACUTE SETTING

103
Q

T/f: you can use benzo’s and opiates for LBP

A

AVOID these!
Can use valium 1x if in ACUTE SETTING

104
Q

Tx goals for LBP:
when to get to baseline?

A
  • Try to get back to baseline activity in 4 weeks
105
Q

Tx goals for LBP:
RTC?

A
  • Re-eval in 4 weeks – sooner if uncontrolled pain, progressive symptoms
106
Q

Tx goals for LBP:
Exercise?

A

*Walk 20min 3-4x/wk

107
Q

LBP ER precautions (6)

A

**uncontrolled pain
fever
loss of bowel/bladder
inability to urinate
inability to abulate
leg weakness

108
Q

What type of pain is trigger point injections good for?
What is a good agent for injection?

A

chronic focal pain
Marcaine

109
Q

What type of pain is gabapentin/lyrica good for?

A

sig nerve pain. not spasm

110
Q

what type of pain is lidocaine patches good for?
What is voltaren gel?

A

focal pain
topical ibuprofen

111
Q

If ESR (+) in spinal infect pt
what is study of choice?

A

**MRI WWo

112
Q

Will XRay r/o compression fx?

A

no

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