Back pain Flashcards
indications for imaging in lower back pain
underlying concern for malignancy,
osteoporosis or compression fracture,
ankylosing spondylitis,
sensory or motor deficits,
cauda equina syndrome,
suspected epidural abscess or infection
If you order an XR of back in the setting of lower back pain what are you looking for?
osteopososis, compression fracture suspected malignancy ankylosing spondylitis (insidious onset, nocturnal pain, better with movement)
If you order an MRI of the back in the setting of lower back pain what are you looking for?
cauda equina syndrome, suspected epidural abscess and infection (fever, IVDA, concurrent infection, hemodialysis) do it dfor sensory or motor deficits
When do you order a radionuclide bone scan or CT scan
indications for but the patient is unable to have a MRI
Vertebral osteomyelitis presentation
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
Best imaging to look for vertebral osteomyelitis?
MRI is more sensitive than CT scan in initial evaluation
Red flag symptoms of lower back pain
recent UTI, age >50 yrs, nocturnal pain (suggest infecitous evaluation)
neurogenic claudication is also called
pseudoclaudification
symptoms of neurogenic claudication
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
vascular claudification
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
examination consistent with neurogenic claudication
normal pulses frequently normal examination
examination consistent with vascular claudication
decreased pulses, cool extremities, decreased hair growth, pallor with leg elevation
diagnosis of neurogenic claudication
MRI of spine
vascular claudication diagnosis
ABI
lumbar spinal stenosis happens with
>60 yrs old and degenerative spondylosis
red flags for low back pain (which suggest a systemic disorder and not just MSK)
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
what is concerning on physical exam for lower back pain?
point tenderness to palpation on exam and elevated ESR>100 mm/h concerning for vertebral osteomyelitis. may have hx of UTI.
Treatment of vertebral osteomyelitis
IV abx and surgery (if doesn’t improve with abx)
what to do in a vertebral compression fracture initially after being diagnosed via XR?
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.
what to do for vertebral compression fracture pts after pain is controlled?
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
Pain from vertebral compression fracture improves in
4-6 weeks.
what if pain from vertebral compression fracture doesn’t improve?
refractory pain >6 weeks needs to consider a vertebral augmentation (vertebroplasty or kyphoplasty) but these are not recommended acutely
When do we get a MRI or CT after an acute vertebral compression fracture
only if there’s signs of neurological deficits.
Why do we try to avoid excessive bed rest after a vertebral compression fracture
it decreases functional capacity and additional loss of bone density
vertebral compression fracture activity recommendations
resume normal activity avoid excessive bed rest prescribe PT for gait training/core strengthening once pain improves
secondary prevention of vertebral compression fracture
exercise and fall prevention treatment of underlying osteoporosis
uncomplicated back pain is (definition) how is it categories by duration?
with no systemic symptoms or neurological deficits
acute: <4 weeks
subacute: 4-12 weeks
chronic: >12 weeks
acute back pain can be managed with
heating pads, nonsteroidal antiinflammatory drugs
treatment of chronic back pain requires
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
most common type of osteoporotic fracture?
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”.
How to treat pain from osteoporotic vertebral compression fracture
NSAIDS and tylenol. But sometimes can use intranasal calcitonin (not a first line treatment for pain or for osteoporosis)
do we use back braces for vertebral compression factures?
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
bisphosphonates for acute vertebral fracture
used for osteoporosis long term but do not help with acute low back pain from fracture.
what are potential complications of vertebroplasty?
invasive and associated with cement leakage, nerve injury and pulmonary embolism.
acute lumbosacral radiculopathy
likely from mechanical compression of L5 and S1 dorsal root by herniated disc
sciatica:
low back pain and leg pain associated with numbness or weakness in leg
positive straight leg test:
reproduction of radicular pain with flexion at the hip and dorsiflexion at the ankle (positive straight leg raise) and specific for diagnosis
most effective treatment for radiculopathy pain
NSAIDs and light normal activity brief period of bed rest (<3 days) is also acceptable but extended bed rest doesn’t help
If not improved, then may need
MRI and surgical referral if needed.
