Back pain

Question 1

indications for imaging in lower back pain

Answer 1

underlying concern for malignancy,

osteoporosis or compression fracture,

ankylosing spondylitis,

sensory or motor deficits,

cauda equina syndrome,

suspected epidural abscess or infection

Question 2

If you order an XR of back in the setting of lower back pain what are you looking for?

Answer 2

osteopososis, compression fracture suspected malignancy ankylosing spondylitis (insidious onset, nocturnal pain, better with movement)

Question 3

If you order an MRI of the back in the setting of lower back pain what are you looking for?

Answer 3

cauda equina syndrome, suspected epidural abscess and infection (fever, IVDA, concurrent infection, hemodialysis) do it dfor sensory or motor deficits

Question 4

When do you order a radionuclide bone scan or CT scan

Answer 4

indications for but the patient is unable to have a MRI

Question 5

Vertebral osteomyelitis presentation

Answer 5

progressively worsening spinal pain oversal several weeks or months, see spinal percussion tenderness and decreased range of motion but unremarkable. ESR is >80% blood cultures should be done to identify

Question 6

Best imaging to look for vertebral osteomyelitis?

Answer 6

MRI is more sensitive than CT scan in initial evaluation

Question 7

Red flag symptoms of lower back pain

Answer 7

recent UTI, age >50 yrs, nocturnal pain (suggest infecitous evaluation)

Question 8

neurogenic claudication is also called

Answer 8

pseudoclaudification

Question 9

symptoms of neurogenic claudication

Answer 9

post dependent pain lumbar extension worsens pain (walking downhill) and lumbar flexion relieves pain (walking while bent forward) lower extremity weakness and lower back pain

Question 10

vascular claudification

Answer 10

exertionally dependent pain pain relieved with rest but not while bending forward while walking lower extremity cramping and tightness, no significant lower extremithy weakness possible buttock, thigh, calf or foot pain

Question 11

examination consistent with neurogenic claudication

Answer 11

normal pulses frequently normal examination

Question 12

examination consistent with vascular claudication

Answer 12

decreased pulses, cool extremities, decreased hair growth, pallor with leg elevation

Question 13

diagnosis of neurogenic claudication

Answer 13

MRI of spine

Question 14

vascular claudication diagnosis

Answer 14

ABI

Question 15

lumbar spinal stenosis happens with

Answer 15

>60 yrs old and degenerative spondylosis

Question 16

red flags for low back pain (which suggest a systemic disorder and not just MSK)

Answer 16

age >50 yrs history of previous cancer unexplained weight loss pain greater than one month night time pain unresponsive to previous therapy neurological symptoms history of IVDA recent UTI

Question 17

what is concerning on physical exam for lower back pain?

Answer 17

point tenderness to palpation on exam and elevated ESR>100 mm/h concerning for vertebral osteomyelitis. may have hx of UTI.

Question 18

Treatment of vertebral osteomyelitis

Answer 18

IV abx and surgery (if doesn’t improve with abx)

Question 19

what to do in a vertebral compression fracture initially after being diagnosed via XR?

Answer 19

initial management: control pain with simple analgesics (tylenol, NSAIDS), opioid analgesics or inpatient hospitalization for parenteral opioids. no muscle relaxants If pain persists, can give calcitonin nasal spray for pain relief.

Question 20

what to do for vertebral compression fracture pts after pain is controlled?

Answer 20

encourage ambulation and resume normal activity as soon as possible. Need physical therapy to teach core strengthening and gait training for fall prevention. Need to include exercise (Flexibility and balance exercises and resistance training) manage underlying osteoporosis avoid smoking

Question 21

Pain from vertebral compression fracture improves in

Answer 21

4-6 weeks.

Question 22

what if pain from vertebral compression fracture doesn’t improve?

Answer 22

refractory pain >6 weeks needs to consider a vertebral augmentation (vertebroplasty or kyphoplasty) but these are not recommended acutely

Question 23

When do we get a MRI or CT after an acute vertebral compression fracture

Answer 23

only if there’s signs of neurological deficits.

Question 24

Why do we try to avoid excessive bed rest after a vertebral compression fracture

Answer 24

it decreases functional capacity and additional loss of bone density

Question 25

vertebral compression fracture activity recommendations

Answer 25

resume normal activity avoid excessive bed rest prescribe PT for gait training/core strengthening once pain improves

Question 26

secondary prevention of vertebral compression fracture

Answer 26

exercise and fall prevention treatment of underlying osteoporosis

Question 27

uncomplicated back pain is (definition) how is it categories by duration?

Answer 27

with no systemic symptoms or neurological deficits

acute: <4 weeks
subacute: 4-12 weeks
chronic: >12 weeks

Question 28

acute back pain can be managed with

Answer 28

heating pads, nonsteroidal antiinflammatory drugs

Question 29

treatment of chronic back pain requires

Answer 29

multidisciplinary rehab program with PT (w/ recommendations for home exercise program), occupational therapy, and cognitive behaviorial therapy to help with improving pain and functional status better than single modality approach. obese people may go and lose weight

Question 30

most common type of osteoporotic fracture?

Answer 30

60% of osteoporotic vertebral fractures are clinically silent but symptomatic pts can experience pain for 2-6 weeks which can radiate down and create a “girdle of pain”.

Question 31

How to treat pain from osteoporotic vertebral compression fracture

Answer 31

NSAIDS and tylenol. But sometimes can use intranasal calcitonin (not a first line treatment for pain or for osteoporosis)

Question 32

do we use back braces for vertebral compression factures?

Answer 32

people use them but clear cut data shows that the efficacy of this is lacking. Not effective for acute pain relief either and limit mobilization and promote disuse osteoporosis

Question 33

bisphosphonates for acute vertebral fracture

Answer 33

used for osteoporosis long term but do not help with acute low back pain from fracture.

Question 34

what are potential complications of vertebroplasty?

Answer 34

invasive and associated with cement leakage, nerve injury and pulmonary embolism.

Question 35

acute lumbosacral radiculopathy

Answer 35

likely from mechanical compression of L5 and S1 dorsal root by herniated disc

Question 36

sciatica:

Answer 36

low back pain and leg pain associated with numbness or weakness in leg

Question 37

positive straight leg test:

Answer 37

reproduction of radicular pain with flexion at the hip and dorsiflexion at the ankle (positive straight leg raise) and specific for diagnosis

Question 38

most effective treatment for radiculopathy pain

Answer 38

NSAIDs and light normal activity brief period of bed rest (<3 days) is also acceptable but extended bed rest doesn’t help

Question 39

If not improved, then may need

Answer 39

MRI and surgical referral if needed.