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Pocket Primary Care > Back Pain > Flashcards

Back Pain Flashcards

1
Q

Epidemiology

A

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.

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2
Q

Etiologies of back pain

A 
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%)
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3
Q

Common Presenting Symptoms

Muscle or ligament injury

A

Sudden onset of pain, often w/precipitating movement, may radiate to buttock, upper thigh; feeling of something giving way.

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4
Q

Common Presenting Symptoms

Degenerative joint disease

A

chronic, subacute pain often assoc w/other OA

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5
Q

Common Presenting Symptoms

Disk Hernation

A

L5-S1 most common; + straight leg test; worse w/coughing, straining; sciatic pain (sharp/burning, radiating down buttock, thigh, or leg) in dermatomal distribution.

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6
Q

Common Presenting Symptoms

Compression Fracture

A

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.

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7
Q

Common Presenting Symptoms

Spinal stenosis

A

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

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8
Q

Common Presenting Symptoms

Spondylolisthesis

A

Forward subluxation of vertebrae causes chronic ligamentous pain worse w/activity, relieved by rest

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9
Q

Common Presenting Symptoms

Malignancy

A

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

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10
Q

Common Presenting Symptoms

Epidural abscess, vertebral osteomyelitis, discitis

A

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

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11
Q

Common Presenting Symptoms

Spondyloarthropathies

A

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

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12
Q

Common Presenting Symptoms

Extraspinal

A

Referred pain from hip, SI joint; AAA/TAA, endometriosis, fibroids, nephrolithiasis, pancreatitis, cholecystitis, pyelonephritis, neuropathy, claudication

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13
Q

L4 Sensory

A

Pain radiating to anterior thigh; sensory abnormalities anterior-lateral thigh, medial calf

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14
Q

L5 Sensory

A

Pain to buttock, down lateral thigh and calf to foot; sensory abnormalities lateral calf, great toe

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15
Q

S1 Sensory

A

Pain to buttock, down posterior tight/calf to lateral foot; decrease sensation plantar/lateral foot, posterior leg

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16
Q

L4 Motor

A

Difficulty rising from chair, extending leg at knee, heel walk; decrease patellar reflex

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17
Q

L5 Motor

A

Difficulty w/heel walk, dorsiflexion of great toe; normal reflexes

18
Q

S1 Motor

A

Difficulty w/toe walk; decrease plantarflexion of toe and foot; decrease ankle reflex

19
Q

History

A

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

20
Q

Occupational Injury

A

Documentation of injury history, functional limitation; risk factors for chronic disabling back pain include pre-existing psychological problems/chronic pain, job dissatisfaction

21
Q

Exam

A

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

22
Q

Straight-leg test

A

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.

23
Q

Crossed straight-leg raise

A

elevation of opposite leg reproduces sx (increase specific)

24
Q

Workup

A

Hx/PE suggestive in most cases; imaging in absence of red flags does not improve clinical outcomes; abnl findings common in asx pts

25
Q

Labs

A

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

26
Q

Radiographs

A

Useful in diagnosing compression fractures, ankylosing spondylitis

27
Q

MRI

A

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

28
Q

EMG and NCS

A

Useful in pts w/subacute radiculopathy and an unrevealing MRI

29
Q

Red Flags to Prompt Imaging

A 
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 &amp; 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
30
Q

Acute/Subacute timeframe

A

<12 wks

31
Q

Acute/Subacute

Urgent surgical eval

A

Indicated for cauda equina, motor weakness, cord compression

32
Q

Acute/Subacute

Medications

A

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

33
Q

Acute/Subacute

nonpharmacologic

A

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

34
Q

Chronic timeframe

A

> 12 weeks

35
Q

Chronic

Epidural steroid injection

A

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

36
Q

Chronic

Medications

A

SNRIs, TCAs

37
Q

Chronic

Behavioral modifications

A

Wt loss, cognitive behavioral RX, smoking cessation

38
Q

Chronic

Herniated discs and spinal stenosis

A

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

39
Q

Chronic

Vertebral Fusion

A

Degenerative spondylolisthesis w/laminectomy; consider for pts w/>1y disabling nonspecific back pain refractory to behavioral modification/intensive interdisciplinary rehabilitation

40
Q

Chronic

Osteoporotic Compression Fractures

A

Vertebroplasty provided no benefit compared to sham procedures

41
Q

Chronic

Other (multidisciplinary specialist consultation recommended)

A

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

Pocket Primary Care (18 decks)

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