Back Pain Flashcards
Why do primary care docs need to know about back pain?
80% lifetime prevalence
12-15% of visits to PCP
Why is the disc a source of lower back pain?
discs are avascular: hard to heal. have pain receptors in cartilage and endplates. designed to absorb shock.
What is the best treatment for lower back pain? What are challenges of back pain diagnosis?
best treatment is spinal stabilization: exercises that stabilize core muscles can help.
diagnosis is challenging and we can only provide an etiologic diagnosis in 10-15% of patients.
What are some rare but serious conditions you must always consider if a patient comes in with back pain?
cancer
spinal fracture
cauda equina syndrome
infection like osteomyelitis or discitis
What are some red flags in the history for a patient with back pain?
bowel/bladder incontinence: may be a sign of cauda equina syndrome (an emergency that requires surgical treatment)
(age over 50)
(pain for over a month without relief)
serious trauma
fever (could indicate infection like osteomyelitis or discitis)
cancer (may indicate metastasis)
steroid use/osteoporosis
weight loss (potential cancer)
Think of it as determining SERIOUS causes of back pain: cancer, fracture, cauda equina syndrome, infection
What are the 5 critical components to an exam for back pain? What am I looking for, on a very basic level?
- General appearance
- Inspection:skin abnormalities (cafe au lait for neurofibromatosis, for example); spine curvature
- Palpation: pain, step-offs
- Neuro exam: effects on spinal cord/nerves
- Provocative tests like straight leg raises for sciatica.
What are the important parts of the neuro exam should you do when evaluating for lower back pain?
motor exam, sensory exam, reflexes, coordination, gait and balance
Which patients should probably have imaging done for lower back pain? Why don’t we image everyone?
pain greater than 1 month
any red flag on history: bladder retention, fecal incontinence, progressive neuro defect, fever, cancer. We don’t image everyone because we don’t want to do unnecessary radiation, it is often not diagnostic, and may show “problems” that aren’t the cause of the actual problem!
What labs might you get for a patient with back pain?. There are 4 of them.
ESR (sedimentation rate) and c reactive protein
(evelation may indicate tumor or infection)
CBC (usually normal for back infections)
HLA b27 (usually positive in alkylosing sponidydis).
also mentions CK
What is the clinical picture of a lumbar compression fracture? What do I do with a lumbar compression fracture?
usually older adults with osteoporosis or a history of chronic steroid use (which causes osteoporosis). Or serious trauma.
this iwll be severe, acute pain.
Refer these patients to orthopedics: the spine may be unstable, which could lead to spinal cord injury.
What is the clinical picture of a patient with a spinal infection?
classically, fever + back pain
may also see spinal tenderness.
often also seen in diabetic patients with a recent UTI, or IV drug users
What is cauda equina syndrome? When might I suspect cauda equina, and what should I do?
SURGICAL EMERGENCY. Disc herniation into the S2-S4 areas.
suspect if you see back pain + urinary retention, fecal incontinence, saddle anesthesia, progressive lower extremity weakness, or abnormal sphincter tone
I need to get an EMERGENCY MRI for this patient, who will need emergency surgery if it is cauda equina.
What is spondyloarthropathy? What are the 2 types, and when would I see each of them?
A connective tissue disease that can be either seropositive or seronegative. seropositive often co-occurs with IBD and psoriasis
seronegative is usually males under 40 with morning stiffness, night time pain, and improved with exercise.
What is spondylolysis/spondylolisthesis?
sports injury most often seen in young adults, usually someone with lots of spinal extension. involves a break in the bony ring of the vertebra with forward slippage (near the tailbone). doesn’t usually require tons of aggressive treatment.
What is lumbar herniation with radiculopathy?
symptoms of back pain and leg pain. often dermatomal pain or sensory symptoms and myotomal weakness. Abnormal reflexes and positive straight leg raise test. most improve within 3 moths on their own (70-90%); otherwise, try surgery, PT, meds, or injections.
