Back Pain Flashcards
What are common red flags for Thoracic Pain?
Fracture Minor trauma (female>50, male>60) Major trauma Malignancy Previous history of cancer Age >50 Unexplained weight loss Pain at rest Constant pain Night pain Pain at multiple sites Failure to improve with conservative care (4-6 weeks duration)
Infection
Recent urinary tract infection
or urinary problems Fever or night sweats
Other serious conditions Chest pain/heaviness
SOB, cough
rattle of some musculoskeletal causes of Thoracic injuries
Systemic causes?
Musculoskeletal: Muscle strain Vertebral or rib fracture Zygapophyseal joint arthropathy Active TPs Spinal stenosis Costotransverse and costovertebral joint dysfunction AS Disk herniation Intercostal neuralgia DISH T4 Syndrome Shoulder impingement Cervical mechanical problems
Systemic:
Referral from Kidney:
Biliary duct
Oesophagus – mid back between scapulae Stomach
Peptic ulcer – mid thoracic T6-10 Gallbladder
Pancreas
Heart – mid thoracic
Cancer: Breast – mid thoracic or upper back Lung Thyroid Hodgkin’s disease Oesophageal
Thocic pain Probable Dx
Serious disorders- need to rule these out.
Pitfalls: things to consider if pt isnt responding and serious already ruled out.
Probable:
- musculoskeletal strains (postural)
- vertebral dysfunction
Serious Disorders:
-Cardiovascular refferal- myocardial infarction, dissecting aneurysm, pulmonary infarction
-Neoplasia: Myeloma, lung, metastatic
Severe infectionsL Pleurisy, infectios endocarditis, osteomyelitis
-pneumothorax
-osteoporosis
Pitfalls: things to consider if pt isnt responding and serious already ruled out.
- Angina
- costo-chondritis
- fibromyalgia
- herpes zoster
- spondyloarthropathies
- chronic infection
- GI disoreders (peptic ulcer, pancreas, oesophageal dysfunction.)
Scapula Pain
pain is usualoly located along vertebral border.
Can be from:
- cardiac
- GI disorders
- musculoskeletal
- pulmonary
- renal
Presentation
-Substernal pain that may radiate to:
neck, upper back, upper trap, left supraclavicular area, left arm, costal margins.
- dysphagia
- pain relieved by leaning forward or sitting upright
- pain reduced while holding breath
- pain aggravated by movement of deep breathing (coughing, laughing, deep inspiration) and laying down
- cough
- lower extremity oedema
Pericarditis
Presentation:
- upper back stiffness and achiness
- assosiated upper extremity numbness and/or parasthaesias (often in a glove distribution)
- may have assosiated headaches
- symptoms usually occur at night or wake the patinet in the early morning
What u think it is?
Examination?
Management plan?
Examination:
+ Tenderness and restrictions in involved segments, usually T2-T7.
Palpation may reproduce symptoms
Neurological exam is normal
Management plan: NSAIDS to reduce inflammation -manipulation/ mobilisation -exercises/ Stretches -lengthen shortened tissues -strengthen weak muscles -restore correct biomechanics
Modalities
‘Achy pain in upper anterior thorax
- located centrally or parasternally
- sometimes worsens to a sharp jabbing pain with activity, sneezing, coughing and deep inspiration
Examination and managament plan
Costochondritis
-middle ribs m.c affected
Examination:
-Tenderness and restrictions at the costal junction of ribs (2-5 m.c)
Management:
- NSAIDS to reduce inflammation
- manipulation not for inflamed state
- exercises/ stretches
- lengthened shortened tissues
- strengthen weak muscles
- restore correct biomechanics
modalities
Presntation:
- burning interscapula pain
- wraps around one side of the thorax to the anterior chest
- exact distribution corresponds to the Nerve root affected.
May include: Hyperparesthesia, parasthesia, dysaesthesia
- red vescicles appearing 2-3 days after pain
- vesicles may last up to 3 weeks
- they can burst leaving a brown crust
What is it? Management plan?
Herpes Zoster (shingles)
- Refer to GP as soon as possible
- antiviral meds within 3 days is most effective treatment
- If after 3 days treatment is aimed at pain control
Herpes Zoster is
Rather than diagnosing lumbar pain, what are the questions we must ask?
- What anatomical structure is affected (SOS)
- Where
- what pathology
We can be as specific as possible with levels etc.
Pathology of Spinal Pain
Specific
Non-specific Spinal Pain
Specific spinal pain: (15-20%)
- specific diagnosis can be made on clinical findings and/or investigations.
- source and mechanisms can be established.
Non-specific pain:
- 80-85%
- specific structure cannot be id’d with certainty (unless invasions procedures used)
- specific or serious pathology ruled out (ie benign)
“Pain occurring primarily in the back with no signs of a serious underlying condition (such as cancer, infection, or cauda equina syndrome), spinal stenosis, or radiculopathy, or another specific spinal cause (such as vertebral compression fracture or ankylosing spondylitis)
Degenerative changes seen on lumbar imaging are usually considered non- specific, as they correlate poorly with symptoms.”
Mechanical Spinal Pain
Diagnosis is based on?
pretty much the same as ‘non-specific spinal pain’
-symptoms are influenced by posture/ loading or movement.
-chiros have a role to play here
eg disc protrusion with low grade radiculopathy.
Diagnosis based on:
- history of symptom onset/ progression
- location, nature and behaviour
- physical exam
- proving relationship between pain and movement/ posture
- identify clinical signs relevant to symptoms (palpation, segmental motion, muscle weakness)
- Identify painful segment or level
- neuro involved
- radiological imaging is available
- medical investigations
- most IMPORTANTLY! Excluding other causes.
Lumbar Pain Red Flags:
Age >50 Previous history of cancer Fever Constant pain- day and night Sudden unexplained weight loss Symptoms in other systems Significant trauma Drug or alcohol use Neurological deficit Use of anticoagulants Use of corticosteroids No improvement over 1 month Possible cauda equina: Saddle anaethesia Bowel/bladder dysfunction Severe or progressive neuro deficit.
Lumbar Pain Yellow Flags?
Belief that pain and activity is harmful Extended periods of rest and other ‘sickness behaviours’ Problems with claim and compensation Heavy work, unsociable hours Poor job satisfaction Management that is not best practice Low or negative moods, or social withdrawal.
Lumbar Pain: 23
Probable Dx
Serious disorders to rule out?
What are the things to consider if patient isnt responding to treatment and the serious conditions have already been ruled out?
Probable: Mechanical/ non specific -strains/ sprains (postural) -especially myofascial, facet joint and disc -spondylosis (degenerative OA)
Serious Disorderes- rule these out
- Cardiovascular refferal (ruptured aortic aneurysm, retroperitoneal haemmorrhage)
- Neoplasia (myeloma, metastatic)
- Severe Infections (epidural abscess, osteomyelitis, discitis, TB)
- Cauda Equina Syndrome
Pitfalls:
- Spondylolithesis
- claudication (vascular or neurogenic)
- prostatis
- endometriosis
- spondyloarthropathies
- AS, Reiters syndrome, Psoriasis
- SI dysfunction
- depression
- spinal dysfunction
- UTI
PT trying to tell you somthing -Stress!
Tips for Lumbar Pain
Reffered low back pain usually comes from?
back pain can be assosiated with?
Reffered LBP usually comes form: -GI -Pulmonary -Urologic _gynaecological system
Back pain can be associated with:
- perforation or distention of organs mentioned above
- pain can occur from
- compression
- ischaemia
- infection
- colicky pain- spasm of hollow viscus
- severe, tearing pain with sweating and dizziness- AAA
- burning pain- duodenal ulcer
- > 50 with back pain, insidious onset, unknown cause = must have vital signs taken.
