BACK PAIN

Question 1

What are the 2 most common reasons people present to the ED? (1st & 2nd)

Answer 1

1st = URI 2nd = Back pain

Question 2

What is the best approach when working with a patient who has back pain?

Answer 2

Look for red flags & exclude serious causes → majority of patients have non-specific etiology

Question 3

What are the concerning risk factors for back pain?

Answer 3

Age less than 18 or over 50

History of IVD, CA, immunocompromised, recent bacterial infection & surgeries

Hx of trauma

Systemic complaints (fever, night sweats, weight loss, malaise)

**Night pain, unrelenting pain, pain worse with cough/Valsalva, pain with ANY neurological deficits (weakness, numbness, gait problems, urinary or stool retention/incontinence, saddle anesthesia)

Question 4

If we have a younger patient, 18, who presents with low back pain. We decide to get an HLAB27 and it’s positive – what diagnosis?

Answer 4

Anklyosing Spondylitis

Question 5

If an 82 year old woman had aggressive coughing from pneumonia and now has back pain – what do we need to think of? What do we need to rule out?

Answer 5

Compression fx → r/o if it is stable or not

Question 6

What’s the difference between sciatica & spinal stenosis?

Answer 6

Sciatica = nerve compression from disc, inflammation, or muscle

Spinal stenosis = narrowing of the spinal canal (occurring over time)

Question 7

If a patient is an IVD and has back pain – what do we need to think of?

Answer 7

Osteomyelitis

Question 8

If an older patient has back pain what is one thing that should always be on ddx?

Answer 8

AAA!

Question 9

So a patient has back pain, what can you not forget to do during the PE?

Answer 9

LOOK AT THE SKIN → pt should be down to underwear & johnny

(remember don’t do $14K workup only to find out its Zoster…)

Question 10

If a patient can walk on their heels is what nerve? What about on their toes?

Answer 10

Heels = L5 Toes = L4

Question 11

The patellar reflex is testing what level? What about Achilles?

Answer 11

Patellar = L3/4             
Achilles = S1

Question 12

What are some special tests you should consider for LE sxs with low back pain?

Answer 12

SLR; cross SLR; Light touch sensation; rectal tone & saddle anesthesia; and palpate bladder (see if it’s still full after going)

Question 13

What test is positive with sciatica?

Answer 13

SLR & Crossed SLR

Question 14

Where is the most common place for hernias to occur?

Answer 14

L4-5 & L5-S1

Question 15

What is the imaging of choice when looking at the spinal cord (infx, compression, neoplasm)? What about if we are looking for vertebral fractures?

Answer 15

Spinal cord = MRI
Vertebral fx = CT
*But remember to always start with an xray!

Question 16

SO if a patient comes into the ER and they have some sensory changes in the leg & you realize that they have neurological weakness of that leg as well – what do you do next?

Answer 16

Get an MRI! Might need emergent surgery if it’s a compression syndrome

May need to consider MRI with 10mg IV dexamethasone → OF THE ENTIRE SPINE!!!

*But make sure you also ask about autonomic functions

Question 17

If you find that a patient has a spinal infection – how do you treat them?

Answer 17

Admit,
Consult with surgeon,
IV Abx

Question 18

In general, how do we treat non-specific back pain?


Answer 18

Options = NSAID & Tylenol;
muscle relaxants;
Opioids (holy grail);
& ACTIVITY (not bed rest)

Question 19

If we decide to prescribe an opioid what should we remember?

Answer 19

Consider a drug screen first (to make sure); look them up on PMP system; and SHORT TERM USE ONLY