Back Pain Flashcards
Epidemiology
2nd most common complaint in primary care, 66% lifetime risk in adults;60-70% of cases resolve in 6 weeks, 80-90% by 12 weeks.
Etiologies of back pain
Muscular or ligament injury (70%) Degenerative joint disease (10%) Disk Herniation (4%) Compression fracture (4%) Spinal stenosis (3%) Spondylolithesis (2%) Malignancy (<1%) Epidural abscess, vertebral osteomyelitis, discitis (0.1%) Spondyloarthropathies (<1%) Extraspinal (2%)
Common Presenting Symptoms
Muscle or ligament injury
Sudden onset of pain, often w/precipitating movement, may radiate to buttock, upper thigh; feeling of something giving way.
Common Presenting Symptoms
Degenerative joint disease
chronic, subacute pain often assoc w/other OA
Common Presenting Symptoms
Disk Hernation
L5-S1 most common; + straight leg test; worse w/coughing, straining; sciatic pain (sharp/burning, radiating down buttock, thigh, or leg) in dermatomal distribution.
Common Presenting Symptoms
Compression Fracture
Sudden onset of pain in pt w/risk factors for fracture (ie osteoporosis, steroid use, malignancy, elderly) after coughing, bending, lifting, or minor trauma; loss of height, point tenderness; may be presenting sign of osteoporosis.
Common Presenting Symptoms
Spinal stenosis
Pain in lower back, buttocks (pseudoclaudication), wide gait, paresthesia’s (often bilateral), worsened by standing, walking (downhill>uphill, in contrast to claudication) and decrease by sitting/bending/leaning forward
Common Presenting Symptoms
Spondylolisthesis
Forward subluxation of vertebrae causes chronic ligamentous pain worse w/activity, relieved by rest
Common Presenting Symptoms
Malignancy
Gradual onset of pain w/ activity, unrelieved/worsened by supine position; may be accompanied by incontinence/urinary retention, saddle anesthesia, muscle weakness, wt loss; breast; gi; lung; lymphoma/leukemia, myeloma, and prostate most common malignancies
Common Presenting Symptoms
Epidural abscess, vertebral osteomyelitis, discitis
Fever, back pain, neuro deficit in minority of pts; risk factors include instrumentation, HIV, IVDU or TB, and hematogenous seeding from a UTI, catheter, or abscess
Common Presenting Symptoms
Spondyloarthropathies
Skeletal manifestations of psoriatic arthritis, IBD; AS; onset of pain insidious, improves w/motion, worse in the morning/better at night, and typically occurs in female patients 20-40 years
Common Presenting Symptoms
Extraspinal
Referred pain from hip, SI joint; AAA/TAA, endometriosis, fibroids, nephrolithiasis, pancreatitis, cholecystitis, pyelonephritis, neuropathy, claudication
L4 Sensory
Pain radiating to anterior thigh; sensory abnormalities anterior-lateral thigh, medial calf
L5 Sensory
Pain to buttock, down lateral thigh and calf to foot; sensory abnormalities lateral calf, great toe
S1 Sensory
Pain to buttock, down posterior tight/calf to lateral foot; decrease sensation plantar/lateral foot, posterior leg
L4 Motor
Difficulty rising from chair, extending leg at knee, heel walk; decrease patellar reflex
L5 Motor
Difficulty w/heel walk, dorsiflexion of great toe; normal reflexes
S1 Motor
Difficulty w/toe walk; decrease plantarflexion of toe and foot; decrease ankle reflex
History
Location, provocative/palliative factors, quality, radiation, severity, timing, hx trauma/back pain
Assoc sx: fever, bowel/bladder incontinence, neuro deficits, saddle anesthesia
Risk factors: steroid use, malignancy, infection, depression, avoidance behaviors, ergonomics
Occupational Injury
Documentation of injury history, functional limitation; risk factors for chronic disabling back pain include pre-existing psychological problems/chronic pain, job dissatisfaction
Exam
Flexibility of spine; palpation of spine; toe/heel walk, rising from chair, neuro exam (strength, sensation, reflexes); pedal pulses; observation of walking; spontaneous activity (getting on/off table, getting dressed) helpful; exam of hip joint
Straight-leg test
Somewhat useful for detecting herniated discs (91% sensitive, 26% specific); with patient supine and leg extended, examiner lifts leg at heel -> considered + if sciatica reproduced between 30-70 degrees.
Crossed straight-leg raise
elevation of opposite leg reproduces sx (increase specific)
Workup
Hx/PE suggestive in most cases; imaging in absence of red flags does not improve clinical outcomes; abnl findings common in asx pts
Labs
Guided by clinical scenario; consider ESR/CTP, CBC, BCx, A0, HLA-B27 (inpts w/idiopathic back pain >3 months and <45 years w/possible spondyloarthritis); for pts on chronic opiods, random drug testing to assess for presence of opiods (prevent diversion) and detect substance use d/o
Radiographs
Useful in diagnosing compression fractures, ankylosing spondylitis
MRI
Cauda equina syndrome, epidural abscess, malignancy, approx. 2/3rds of healthy adults without back pain have abnl findings on spine MRI and sc may not relate to imaging findings
EMG and NCS
Useful in pts w/subacute radiculopathy and an unrevealing MRI
Red Flags to Prompt Imaging
Unexplained fevers or wt loss Immunosuppression Age>70 y Osteoporosis Duration >6 wks Indwelling catheter, recent UTI or cellulitis Bowel/bladder incontinence Trauma/heavy lifting & age >50 y Hx malignancy of IVDU Prolonged steroid use Focal neuro deficit New back pain in pt >50 y Pain at night Urinary retention
Acute/Subacute timeframe
<12 wks
Acute/Subacute
Urgent surgical eval
Indicated for cauda equina, motor weakness, cord compression
Acute/Subacute
Medications
APAP+/- NSAIDs: 1st-line, scheduled for short course
Topicals: lidocaine, capsaicin
Muscle Relaxants: cyclobenzaprine, baclofen, tizanaidine, methocarbamol, may be combined w/NSAIDs for short course; caution re: sedation, drug interactions; avoid cyclobenzaprine in pts w/arrhythmia, CHF, hyperthyroid: low-dose diazepam may also be used (2nd line 2/2 abuse potential)
Opiods: Should be used sparingly and only for a short course if needed
Bisphosphonates: Pts w/ osteoporotic compression fractures and pain unrelieved by PO meds
Acute/Subacute
nonpharmacologic
Physical activity as tolerated: pain relief/function improved in pts advised to stay active compared to bed rest
Reassurance: 90% of pts w/acute, nonspecific back pain improve in <2 weeks w/o intervention
CAM: physical therapy, yoga (chronic low back pain), acupuncture, chiropractic, aquatherapy, massage tx; heat; cold compresses (acute back pain)
Self-care: education books (eg the back book); back braces or abdominal binders
Lifestyle modification: Good lifting techniques (bend knees, not back): lay flat w/ pillow under knees to straighten spine; firm/tempurpedic mattress; workplace ergonomic eval; padded mats if pt must stand for long periods; evidence low quality by may be helpful
Chronic timeframe
> 12 weeks
Chronic
Epidural steroid injection
Consider for chronic radicular pain from disk herniation; Cochrane review found “insufficient evidence to support use in subacute and chronic low back pain…it cannot be r/o that specific subgroups of pts may respond” Contaminated steroids assoc w/2012 fungal meningitis outbreak
Chronic
Medications
SNRIs, TCAs
Chronic
Behavioral modifications
Wt loss, cognitive behavioral RX, smoking cessation
Chronic
Herniated discs and spinal stenosis
Surgical correction for herniated discs (discectomy or microdiscectomy) or sx spinal stenosis (laminectomy or intraspinous spacer implantation) assoc w/short-term benefits compared to conservative mgmt. that diminish over time; pts treated w/nonoperative mgmt. for herniated discs improv substantially over 2 y
Chronic
Vertebral Fusion
Degenerative spondylolisthesis w/laminectomy; consider for pts w/>1y disabling nonspecific back pain refractory to behavioral modification/intensive interdisciplinary rehabilitation
Chronic
Osteoporotic Compression Fractures
Vertebroplasty provided no benefit compared to sham procedures
Chronic
Other (multidisciplinary specialist consultation recommended)
Best evidence for multidisciplinary rehab/chronic pain clinic and CBT; other options include ablation, intrathecal analgesic pumps; chronic pain clinic referral; pts who fail back surgery for disc herniation may benefit from spinal cord stimulation; facet joint injections
