Back pain Flashcards
General groups of causes of low back pain
- non-specific mechanical low back pain
- spinal stenosis
- disc herniation with radiculopathy
- infectious/inflammatory
- vertebral body metastasis
- referred/non-orthopedic causes
Predisposing factors for mechanical low back pain
- previous injury
- older age
Categories of mechanical low back pain
- muscle strain
- degenerative disease
Discriminating features of mechanical low back pain
- usually in lumbosacral area
- generally does not radiate below knee
- worse with activity and better with rest
- generally does not wake pt. from sleep
- acute, recurrent, or chronic
Physical exam features of mechanical low back pain
- many features may appear normal
- tenderness or spasms over paraspinal muscles
- kyphosis for osteoporotic fracture
- range of motion may be decreased
- radiologic findings normal unless spondylolysis
Forms of degenerative disease in mechanical low back pain
- disc herniation without root compression
- spondylolisthesis
- spondylolysis
- osteoarthritis
Spondylolysis
defect in vertebral arch causing separation from vertebral body
Spondylolisthesis
vertebral body slides anteriorly over vertebral body below, may cause spinal cord compression
-common in pregnant women!
Pathophysiologic insult of spinal stenosis
hypertrophic degeneration of ligaments or facets, causing narrowing of canal
Predisposing factors for spinal stenosis
- older age
- congenital abnormalities (achondroplasia)
- metabolic or endocrine disorders
Discriminating features of spinal stenosis
- usually chronic
- usually lumbosacral area
- common associated buttock or leg pain
- pain worse with walking or standing, relieved with sitting
Physical exam features of spinal stenosis
-nonspecific unless radiculopathy
Pathophysiologic insult of disc herniation with radiculopathy
- herniation of nucleus pulposus
- nerve root injury secondary to compression or inflammation
Predisposing factors for disc herniation with radiculopathy
- trauma or severe strain
- severe coughing or val salva maneuver
Discriminating features of disc herniation with radiculopathy
- acute or acute on chronic
- usually lumbosacral area
- pain radiates down leg below knee!
- associated numbness, tingling, or weakness or dermatomal sensory loss
- may cause bladder or bowel dysfunction
- usually worse with movement and better with rest
- usually worse with coughing, val salva, or sitting
Physical exam features of disc herniation with radiculopathy
- tenderness over paraspinal muscles
- range of motion may be decreased
- neurologic signs correlating with root level!
- motor weakness, loss of light touch sensation, decreased reflexes
- MRI or CT show disease
Infectious/inflammatory conditions of lower back pain
- vertebral osteomyelitis
- discitis
- epidural or paraspinous abscess
Pathophysiologic insult of infectious/inflammatory causes of low back pain
- localized inflammation
- acute (Staph aureus) or chronic
Predisposing factors for infectious/inflammatory low back pain
- IV drug use
- history of recent/intermittent infection
Discriminating features of infectious/inflammatory low back pain
- acute, progressive, or chronic
- can occur at any location
- no relief with rest
- often wakes patients from sleep!
- systemic symptoms: fever, chills, fatigue
- if chronic, weight loss and night sweats
Physical exam features of infectious/inflammatory low back pain
- fever
- point tenderness on palpation
- may have limited range of motion
- typically normal neurologically
- MRI typically shows infection
- other indicative labs: high WBC, high ESR/CRP, or blood cultures
Predisposing factors for vertebral malignancy
- history of previous or current cancer
- family history of cancer
Pathophysiologic insult of vertebral malignancy
- metastasis of cancer from primary site
- infiltration of bone tissue by malignant cells
Discriminating features of vertebral malignancy
- acute or chronic
- localized or diffuse
- constant, dull
- presence at night or wakes patient from sleep!
- no relief with rest
- systemic symptoms: weight loss, night sweats, fever
- variable neurologic symptoms, present if mass effect
Physical exam features of vertebral malignancy
- may be ill-appearing
- point tenderness on palpation
- may have limited range of motion
- neurologic symptoms if mass effect
- MRI may show metastases in vertebral bodies
Types of referred/non-orthopedic causes
- pancreatitis
- pyelonephritis
- aortic aneurysm
Pathophysiologic insult of pancreatitis
- inflammation of pancreas
- may involve obstruction of pancreatic duct
- release of destructive pancreatic enzymes, which autodigest pancreatic tissue
Predisposing factors for pancreatitis
- alcoholism
- biliary tract disease
- medication use
Discriminating features of pancreatitis
DON’T MISS DX
- acute and persistent
- epigastric, radiating to back!
- relieved somewhat with sitting forward
- worse when supine
- worse with alcohol or fatty meals
- associated with fever, nausea, and vomiting
Physical exam features of pancreatitis
- possible fever and tachycardia
- may be ill-appearing with apparent pain
- epigastric tenderness, sometimes with abdominal rigidity
- may have lower lung crackles or diminished breath sounds (with pleural effusion)
- normal back and neurologic exams
- ultrasound and CT may show disease
- cholangiopancreatography (MR or endocope) may show
- pancreatic enzymes elevated
- high WBC, anemia
- elevated BUN, liver enzymes, bilirubin
Pathophysiologic insult of pyelonephritis
- introduction of bacteria into bladder, ascending up ureters to kidneys
- urinary stasis
- inflammatory reaction
Predisposing factors for pyelonephritis
- frequent sexual activity or pregnancy
- previous UTI or kidney disease
- anatomic abnormalities
Discriminating features of pyelonephritis
- acute, gradual onset, progressive pain
- lower abdominal or unilateral flank pain
- associated fever, chills, nausea, vomiting, dysuria, hematuria, foul urine odor
- elderly patients may present with altered mental status!
Physical exam features of pyelonephritis
- fever, tachycardia
- may be ill-appearing
- vomiting and anorexia may lead to dehydration
- lower abdominal tenderness
- costovertebral angle tenderness on palpation
- urinalysis, urine culture, and/or renal ultrasound may show
Pathophysiologic insult of aortic aneuysm
- weakness in one or more layers of vessel wall
- dilation of blood vessel often with blood accumulation in vessel wall
- pressure may increase and lead to rupture
Predisposing factors for aortic aneurysm
- men
- elderly
- tobacco and alcohol use
- atherosclerosis, HTN, trauma, syphilis
Distinguishing features of aortic aneurysm
- acute, acute on chronic, or chronic
- acute severe pain associated with dissection
- may have thoracic “tearing” chest pain or vague abdominal pain
- assoc. features depend on location
Physical exam features of aortic aneurysm
- if thoracic:
- bradycardia
- differences in right carotid and left radial pulses
- asymmetric arm blood pressures
- if abdominal:
- pulsatile mass in central abdomen
- aortic bruit
