Back Pain Flashcards
Neurosurgical Emergencies
- Cauda Equina Syndrome - Alternating or bilateral root pain in the leg, saddle paresthesia, urinary and fecal incontinence and lower back pain
- Acute Cord Compression - Bilateral pain, lower motor neuron at level of compression and upper motor neuron and sensory loss below the level of compression and sphincter disturbances.
Back Pain Red Flags
Sciatica
(Pain radiating from the buttocks down the leg, tingling sensation, numbness)
Exercise, massage, yoga
OTC meds- Acetaminophen, NSAIDS, Aspirin, muscle relaxants
Lumbosacral pain
Subacute and Acute <12 weeks
Self-care strategies- alternating cold and heat and continuation of usual activities as tolerated
Recommend physical activity
Consider analgesics- acetaminophen then NSAIDs and short course of muscle relaxants
Follow up in 4wks if symptoms get worse refer (physical therapist)
Chronic >12 weeks
Prescribe physical or therapeutic exercise
Analgesia- acetaminophen, NSAIDs (severe pain) -opioids
Low dose TCA’s
Refer to rehab
Additional- muscle relaxants, acupuncture, massage therapy
Spondylolysis
Spondylolysis is a stress fracture in one of the vertebrae. The injury most often occurs in children and adolescents who participate in sports that involve repeated stress on the lower back, such as gymnastics, football, and weightlifting.
Spondylolisthesis
Spondylolisthesis is when the stress fracture weakens the bone so much that it is unable to maintain its proper position in the spine—and the vertebra starts to shift or slip out of place.
Ankylosing Spondylitis / Spondylolisthesis
15- 30 years
Identifiers: Adolescent athletic patient with sudden onset of back pain that is initially sharp and then becomes dull and worsen by activity and relieved by rest. Often radiates to buttocks or thighs.
Ankylosing Spondylitis / Spondylolisthesis
History:
Adolescent patient
Athletic
Typically, asymptomatic and discovered incidentally via X-ray
If symptomatic:
-pain is similar to muscle strain
-may radiate to buttocks and thighs
-worsens with activity and improves with rest
Examination
Pain elicited with hyperextension of spine
Diagnosis:
A thorough history and physical examination is required
Plain x-ray can show fracture of the pars interarticularis in the vertebra to confirm the diagnosis.
CT/MRI Scan can be used to detect very small fractures or rule out other conditions that can cause back pain.
Treatment:
Non-pharmacological: wearing a back brace, physical therapy exercise, spinal fusion surgery
Pharmacological: NSAIDS, epidural steroid injections
Muscle Strain
20-40yrs
Definition: A back strain is an injury to either a muscle or tendon
Identifier - Dull / Aching back pain that increases with activity or bending with a history of recent trauma, heavy lifting or stress that improves with rest and is often localized and unilateral.
History
-Recent Trauma, Heavy lifting or Stress.
-Axial (mechanical) pain, often localized and unilateral, usually dull or aching.
-Typically, 20-40 yrs.
-Improves with rest.
Examination
-Asymmetrical muscle spasms/tenderness.
-Limited range of movement.
-Localized swelling.
Diagnosis:
Laboratory Tests: No abnormalities
Radiographs: Usually negative
Treatment:
Non-pharmacological: ice or heat application, wear a back brace for support, physical therapy
Pharmacological: Acetaminophen, NSAIDS (ibuprofen and naproxen)
Disc herniation
30-50yrs
Definition: A herniated disc is a condition in which the annulus fibrosus (outer portion) of the vertebral disc is torn, enabling the nucleus (inner portion) to herniate or extrude through the fibers. The herniated material can compress the nerves around the disc and create pain that can radiate through the back and sometimes down the arms (if the herniation is in the cervical spine) and legs (if the herniation is in the lumbar spine).
Identifier - Sharp pain +/- Sciatica that improves on standing or lying supine with a history of trauma or heavy lifting and a supine straight leg test giving pain radiating below the knee.
Sciatica refers to pain that radiates along the path of the sciatic nerve, which branches from your lower back through your hips and buttocks and down each leg. Typically, sciatica affects only one side of your body.
History
-Aggravating factors: sitting, bending forward, coughing, sneezing.
-Sharp pain +/- Sciatica.
-Typically, 30-50 yrs.
-Improves on standing or lying supine
Examination:
Supine straight leg test causes pain radiating down the leg and below the knee.
Investigations:
-Usually a clinical diagnosis.
-MRI*, CT, and Myelogram are equally sensitive.
Diagnosis:
Laboratory Tests: No abnormalities
Radiographs: possibly narrowed intervertebral disc spaces on radiographs, CT and MRI can reveal level and degree of herniation, myelography localizes site of disc herniation and the presence of root entrapment
Treatment:
Non-pharmacological: rest and activity modification, ice and heat application, physical therapy, surgery
Pharmacological: NSAIDS, Oral Steroid Medications (Prednisone, Medrol), opioids based on the severity of the pain, muscle relaxers, epidural steroid injection (Cortisone)
Osteoarthritis
> 50 years
Definition: Osteoarthritis (OA), which is also known as osteoarthrosis or degenerative joint disease(DJD), is a progressive disorder of the joints caused by gradual loss of cartilage and resulting in the development of bony spurs and cysts at the margins of the joints.
Identifier - Over age 50, with slowly worsening back pain that is aggravated by walking up an incline and decreases in sitting or lying supine. May have joint stiffness on awakening or after inactivity.
History:
-Slow development, worsening over time.
-Stiffening of neck and back with aching pain.
-Typically, >50 yrs.
-Improves on lying supine.
- Aggravating or Relieving Factors: increased with walking, especially up an incline, decreased with sitting
Examination:
-Pain elicited with any movement of the spine.
Investigations:
-X-ray*, MRI.
Diagnosis:
Laboratory Test: ESR and WBC count plus differential typically normal
Radiographs: asymmetric narrowing of joint space, sclerotic subchondral bone, marginal osteophyte formation
Treatment:
Non-pharmacological: physical therapy, joint replacement surgery (arthroplasty)
Pharmacological: acetaminophen, NSAIDS, cortisone injections, lubrication injections
Spinal Stenosis
> 50 years
Definition :
Identifiers: Over age 50, with worsening back pain when standing/walking downhill and relieved by walking uphill, bending forward, or resting.
History:
Patient >50 years
Worsening pain when standing/ walking downhill
Relieved at rest, bending forward or walking uphill
Paresthesia
Examination:
Simian stance
Wide based gait
Abnormal Romberg test
Thigh pain following 30 secs. of lumbar extension
Investigations
MRI
Treatment:
Non- Pharmacological: Physical therapy, Surgery (decompression)
Pharmacological: Acetaminophen, NSAIDS (Aspirin), Opioids (Morphine and Codeine)
