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.
What is oncologic Spine pain? 27
- sever weakness without pain
- weakness with full range
- constant pain does not vary with activity or position (day/night)
- Skin temp differences from side to side
- progressive neuro deficits (2 or more nerve roots involved)
- positive percussive tap test
- cervical pain or symptoms accompanied by urinary incontinence
- look for signs and symptoms ass with other visceral symptoms.
What are the Red flags for GI involvement?
Dx for GI involvment in Lumbar Pain
Anterior neck or back pain accompanied by any of the following; Oesophageal pain Epigastric pain with radiation to back Dysphagia Odynophagia – pain with swallowing Early satiety or symptoms associated with meals Bloody diarrhoea Faecal incontinence Melena Haemorrhage (blood in the toilet)
Dx for GI involvment:
Oesophagus
Band of pain starting anteriorly and spreading around the chest wall to the back, usually around T5-6
Stomach and Duodenum
Pain in back, usually around T6-10, or shoulder
Blood in stools
Symptoms associated with meals
Relief of pain after eating – immediately or 2 hours later Increased symptoms with or during a bowel movement
Decreased symptoms after a bowel movement
Liver
Palpation of the liver will reproduce symptoms
Back pain, usually no anterior pain
Pain/nausea 1-3 hours after eating (gallstones)
Pain immediately after eating (gallbladder inflammation)
Muscle guarding/tenderness in the right upper quadrant posteriorly associated with fever/chills
Nail bed changes
Palmar erythema
Spider angiomas
Ascites
Jaundice
Presentation:
Intermittent, cyclical or constant pelvic pain and/or back pain – can be unilateral or bilateral
Pain during or after sexual intercourse
Painful bowel movements or painful urination during menstrual period
Heavy or irregular menstrual bleeding
Small blood loss (spotting) before or between periods
Bleeding anywhere else
Fatigue
History of ectopic pregnancy
GI problems
Abdominal bloating and cramping Nausea
Diarrhoea
Constipation
Endometriosis
refer
Presentation:
Abdominal pressure, pain or bloating
Discomfort during urination, bowel movements or sexual intercourse Irregular menses
Infertility
Dull aching low back, buttock, pelvic or groin pain
Sudden, sharp pain with rupture or haemorrhage of cyst
Ovarian Cysts
Presentation:
lumbar pain
Amenorrhoea or irregular bleeding and spotting
Diffuse, aching lower abdominal quadrant or LBP
Can cause ipsilateral shoulder pain
May progress to a sharper, intermittent type of pain
Ectopic pregnancy causing lumbar pain
Presentation: Urinary dysfunction: -hestency -frequency -urgency -nocturia -dysuria
Low back, inner thigh, or perineal pain or stiffness
- suprapubic or pelvic pain
- testicular or penis pain
- bone pain or neurological changes- due to metastases
- sexual dysfunction
- blood in urine
Prostate Pathology
-tips for lumbar Pain
Clinical presentation
Rapid onset of severe neck or back pain
Deep boring pain in midline lumbar region
Sharp, intense, severe or knife-like abdomen, chest or back pain
Pain not relieved by change in position
Pain described as “tearing” or “ripping”
Cold, pulseless lower extremities
Blood pressure differences between arms and legs of more than 10mmHg diastolic
RF:
older male, smokes, Fam Hx
AAA
Medical Emergency
35
Clinical Presentation:
LBP
Unilateral or bilateral sciatica
Saddle anaesthesia
Change in bowel and/or bladder function
Sexual dysfunction
Men – erectile dysfunction Women – dyspareunia
Lower extremity motor weakness and sensory deficits
Gait disturbance
Diminished or absent lower extremity DTR
Cauda Equina Syndrome
in which damage to the cauda equina causes loss of function of the lumbar plexus, (nerve roots) of the spinal canal below the termination (conus medullaris) of the spinal cord. CES is a lower motor neuron lesion.
Presntation:
Pain that has been increasing in
severity over 1-3 weeks
Night pain
Stiff back with difficulty bearing weight, moving or walking
Hip pain if the infection has spread to the psoas muscle
May be constitutional signs
Recent history of bacterial infection
L1 and L2 most affected
Children more likely to have high fever, intense pain, localised oedema, erythema and tenderness
What is it?
What would your examination show?
Whats your managment plan?
Vertebral Osteomyelitis
Examination:
Pain and local tenderness over the involved spinous process/es – this is the most consistent finding
Possible swelling, redness and warmth in the affected area
Paravertebral muscle and hamstring guarding or spasm
Management plan:
Refer
Describe the difference in presentations you would expect between someone presenting with Mechanical back pain and Inflammatory back pain?
Mechanical:
Demonstrates a relationship to movement – ie provoked by activity and relieved by rest
Precipitating injury/previous episodes
Moderate/transient stiffness
Acitivity tends to exacerbate
Diffuse pain that is unilateral
Pain often worse at the end of day or following activity
Inflammatory: Less activity dependent Insidious onset Aching, throbbing Sever, prolonged morning stiffness Rest exacerbates Activity can aid More localised pain but can be bilateral Worst during the night and early morning.
37
What sort of presentation would you expect with someone presenting with facet involvment with back pain
What would be some likely causes?
Examination findings?
Management plan?
-Well localised Lumbar spine pain refferal: -L3-4 to L5-S1= gluteal region -L2-3 to L5-S1 = lateral upper and posterior thigh L1-2 to L4-5 = lumbar region
Causes:
- meniscoid entrapment
- synovial impingement
- joint subluxation
- capuslar and synovial inflammation
- mechanical injury to the joint capsule
- restriction of normal articular motion
Examination:
- Difficult to distinguish from disk
- absense of neuro signs
- localised pain with Kemps test
- aggravated by hyperextension
- sitting upright
Management plan:
- NSAIDS
- manipulations
- exercise/ stretches
- lengthen shortened tissues
- strengthen weak muscles
- restore correct biomechanics
Look at the reffered back pain patterns on slide 39
a
What would be the clinical presentation of Disc Involvement (disruption)
Examination findings
managemnet plan?
40
Clinical presentation:
- lumbar spine pain
- leg pain
- numbness and/or weakness
- refferral (groin, hip, butt and leg)
Examination findings:
- difficult to distinguish from facet
- aggravated by bending forward and coughinh or sneezing
Management plan:
- NSAIDS to reduce inflammation
- manipulations
- exercises/ Stretches
- lengthen shortened tissue, strengthen weak muscles, restore correct biomechanics
- mckenzies
Modalities -learn later
What are the types of disc injuries?
- Disc Buldge:
- diffuse extension of the annulus
- normal feature of disc degeneration
- commonly asymptomatic
Herniations:
- broad term for displacement of material beyond its normal IV space
- Localised (
