Back pain Flashcards by Cat Johnson

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

Nope

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LBP is the __ MC reason for office visits

5th

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What is the MC reason for neurosurgeon or ortho consult?

LBP

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LBP not attributed to spec dz/spinal pathology

Nonspecific LBP
85% of LBP in PC

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

All ages
55-64yo
45y

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

false. this is misleading

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There is more disability from LBP than 3 other conditions combined

CA
Heart dz
CVA

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

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

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What are the 2 main conditions that you CAN NOT miss

Cauda equina
Spinal infect

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Peak age of LBP

55-64

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2 main goals for LBP mgmt

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

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LBP:
Acute
Subacute
Chronic

<4wks
4-12wks
>12wks

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

YES

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Risk factors for development of CHRONIC LBP

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

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

truee

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Red flags for LBP and Acronym

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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H&P besides OLDCAARTS

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

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

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Serious Systemic Causes (4)

Cancer
Spinal Infection
Compression Fx
Ankylosing Spondylitis

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Serious Neurologic causes
req surgery intervention (3)

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

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__% of LBP CA pts are >50y

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

yus

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what are the 3 CA that met to bone/spine

“LBP”
Lung, Breast, Prostate

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spianl CA w/u:

CBC
plain film
direct to possible source

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is night pain a finding in spinal CA?

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

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

Spinal epidural abscess

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

40% source (UTI, indwelling catherters= foley & picc line, skin infection=cellulitis, IVDU*) 60% spontaneous

t/f: fever is sensitive for spinal infect

false. 40%

t/f: spinal tenderness is sensitive for spinal infection

true. 86%

Sources for Spinal infection (MC?)

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

60% of spinal abscess' are ______

spontaneous

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

**MRI WWo

Spinal abscess workup

ESR UA, CBC, Bx Lactate

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

**ESR →EMERGENT MRI Wwo

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

OP 30%

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

Compression fx

Pt profile for compression fx

caucasian female >70

Workup for compression fx. 1st step?

Xray

Will XRay r/o compression fx?

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

**CT wo (XRT doen't r/o)

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

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

Do Kyphoplasty & vertebroplasty have good outcomes?

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

"O-PIMP cane" Onset pn >40yo Progressive, slow pain Imrove w/exerice Morning stiffness Pain >3mo 85% spec w/4/5

Is AS rare?

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

Pt profile ankylosing spondylitis

Caucasian Male >40

Cornerstone finding of ankylosing spondylitis

↓ flexion

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

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

A.S Bilateral or unilateral pain?

Bilateral

Spinal Stenosis Bilateral or Unilateral pain?

Bilateral

Lumbar disc herniation Bilateral or Unilateral pain?

Unilateral

What comes first in LDH Leg pain or back pain?

Leg pain

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

LBP Sciatica

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

95% 2%

peak age lumbar disc herniation

30-55

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

SLR L5/S1

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

SLR AND CLR

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

duh

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

ankle dorsiflexion weakness great toe extensor weakness ↓ pinprick sensation

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

impaired ankle reflex + weak dorsiflexion

What % of L.D.H is asx?

20-30%

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

nope, no ya dont

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

MRI

when to get an MRI w/ LDH

Sig PE findings Pain or sx >6wks

Is spinal stenosis unilateral or bilateral LBP?

BILATERAL

How do we differentiate from PVD?

***check pulses

What is neurogenic claudication? When does it occur?

pn in legs from neuro deficits occurs after stand/walk

Avg age of spinal stenois How many years of Sx?

55 w/4+ yrs of sx

3 Key findings of back pain with spinal stenosis

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

Cornerstone of Spinal stenosis pain

↑ extension "shopping cart people"

Imaging studies of Spinal Stenosis

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

How to Dx Spinal stenosis

MRI or CT w/o of L/S

what is cauda equina?

Massive midline disc herniation → spinal cord compression EMERGENCY!

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

URINARY RETENTION

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

LATE but SENSITIVE

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

Urinary retention 90%

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

"PP-B" Posterior-superior thigh Perianal Buttox

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

yup 60-80%

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

Sciatica SLR+ Sensory/Motor deficits

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

MRI Neurosurg consult

Should you not take a PCP txfr to ER seriously?

HELL NO

Should you change other provider's tx plans?

HELL NO

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?

sounds good

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

True

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

*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

What is the most helpful lab for LBP?

ESR

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

Plain films ESR

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

no, it can still be MSK

Pain evaluation is helpful for activity ____ not activity ____.

Modification Limitation

Where to refer LBP (4)

* 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

4 active LBP therapies

Physical therapy Massage therapy Acupuncture Manipulation

Main 2 points of active LBP therapies

Initiate aggressively & early

EBM Tx of LBP: emphasis on ____ not ____ therapies

Active, not passive

Bed rest for LBP?

Hell no

LBP Tx: Combine __ with ___ therapies

Active w/ pharm

first line Rx for LBP? Which is superior?

NSAIDS /APAP they are the same

Second line tx for LBP that are controversial (2)

* Muscle relaxers - not great, just makes pt not care * Corticosteroids - highly debated, gen not recommended

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

*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

Describe Nerve pain

shooting, burning

Greatest benefit timeline for m. relaxers?

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

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

you can medrol dose pack x1 for sciatica

T/F: benzos are m. relaxers

yes benzos are m relaxers

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

Can use valium 1x if in ACUTE SETTING

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

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

Tx goals for LBP: when to get to baseline?

* Try to get back to baseline activity in 4 weeks

Tx goals for LBP: RTC?

* Re-eval in 4 weeks – sooner if uncontrolled pain, progressive symptoms

Tx goals for LBP: Exercise?

*Walk 20min 3-4x/wk

LBP ER precautions (6)

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

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

chronic focal pain Marcaine

What type of pain is gabapentin/lyrica good for?

sig nerve pain. not spasm

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

focal pain topical ibuprofen

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

**MRI WWo

Will XRay r/o compression fx?