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4. HDS Multisystem > Back Pain > Flashcards

Back Pain Flashcards

1
Q

Low Back Pain (LBP)

Definition

A
  • Symptom and not a diagnosis
  • Need to determine the etiology causing the back pain
  • Acute is < 12 weeks
  • Chronic is > 12 weeks
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2
Q

LBP

Epidemiology

A
  • Lifetime prevalence of LBP = 60-70%
  • Only 30% seek care
  • 2.5% total health care spending in U.S.
  • Chronic back pain is an economic burden for U.S
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3
Q

LBP

Timeline

A
  • Most cases are self-limited
    • 60% better in 1 week
    • 90% better in 6 weeks
    • 95% better in 12 weeks
  • Relapses/recurrences common
    • 25-40% within 6 months
  • Screen for “red flags” to detect serious causes of LBP
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4
Q

Spinal Anatomy

Review

A
  • C1-C7 nerve roots exit above the vertebrae
  • C8 root and below exit below corresponding vertebra
  • Flexion increases the size of the spinal canal; extension decreases it
  • Spinal cord ends at L1 vertebral level
  • Tapers into conus medullaris then into cauda equina
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5
Q

LBP

Differential Diagnosis

A
  • Mechanical LBP (97% of LBP)
    • Lumbar strain (70%)
    • Degenerative disc disease / facet (osteoarthritis)
    • Herniated disc
    • Spinal stenosis
    • Spondylolisthesis
    • Osteoporotic compression fracture
  • Non-mechanical Spinal Conditions (1%)
    • Tumor
    • Infection
    • Inflammatory Arthritis
  • Non-spinal (visceral disease) (2%)
    • Pelvic organs (pelvic inflammatory disease / prostatitis)
    • Renal (nephrolithiasis / pyelonephritis)
    • Aortic aneurysm
    • GI (pancreatitis / peptic ulcer disease)
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6
Q

Lumbar Strain

A
  • Due to strain of muscle fibers and/or ligaments
  • Bleeding and spasm ⇒ tenderness and stiffness in lumbar region
  • Pt usually recalls precipitating incident (lifting/twisting) with immediate onset of pain
  • Pain better when lying supine
  • No neurologic signs/symptoms
  • Pain is local and though may radiate to posterior thighs/buttocks
  • DOES NOT radiate below knee d/t no nerve root involvement
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7
Q

Degenerative Disc Disease

A

“Osteoarthritis of Spine”

  • Causes chronic back pain
  • Narrowing of disc spaces and osteophyte formation
  • May cause radicular symptoms / nerve root compression
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8
Q

Herniated Lumbar Disc

A

Tear of annulus fibrosis ⇒ extrusion of nucleus pulposus

  • Highest prevalence 45-64 year age group
  • 95% occur at L4-L5 or L5-S1
  • Classically precipitated by sudden increased pressure on disc (coughing/lifting)
  • Usually near midline ⇒ compress the nerve root of the vertebra below
  • Moderate to severe pain with radiation to ankle/foot
  • Paresthesias or motor weakness due to pressure on nerve root
  • No bowel/bladder symptoms with unilateral disc herniation
  • Symptoms usually unilateral
  • Forward flexion makes pain worse
    • Sitting (including driving) and lifting
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9
Q

Spinal Stenosis

A

Narrowing of the spinal canal

  • Usually degenerative but may be due to trauma/congenital abnormalities
  • Gradual worsening
  • Leg symptoms usually bilateral
  • Neurogenic claudication
  • Worse with activity (standing/walking) and spine extension
  • Relieved with bending forward or sitting
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10
Q

Claudication Comparison

A
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11
Q

Sciatica

A
  • Sciatic nerve is derived from L4-S3 nerve roots
  • Sciatica ⇒ compression or irritation of sciatic nerve by a low back problem
  • Form of radiculopathy
  • Symptom not a specific diagnosis
  • Etiologies include herniated disc, spinal stenosis, or DDD
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12
Q

Cauda Equina

Syndrome

A

Rare condition caused by tumor or massive midline disc herniation compressing multiple sacral roots.

  • Features:
    • Back pain
    • Urinary retention (loss of detrusor function)
    • Decreased anal sphincter tone
    • Saddle distribution of sensory loss
    • Bilateral sciatica
    • Leg weakness
  • Medical emergency ⇒ needs imaging ASAP and decompression
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13
Q

LBP

History

A
  • Onset
    • Acute vs. chronic
    • Precipitating event / Mechanism of injury
    • Trauma?
    • Sudden vs gradual onset of pain
  • Character
    • Sharp vs dull
  • Location and Radiation
    • Lumbar strain ⇒ paraspinous muscle pain +/- radiation to buttocks
    • Bone pain (metastasis/compression fx) ⇒ usu. localized to spine
    • Radiation below knee ⇒ herniated disk
    • Spinal stenosis ⇒ pain radiating into both legs
    • Cauda equina syndrome ⇒ bilateral symptoms
  • Intensity
    • Severity of pain doesn’t correlate well with etiology
    • Patient factors
    • Gauge it over time OR how it affects daily activities
  • Duration
    • > 12 weeks ⇒ chronic
    • Continuous vs waxes/wanes
      • Rheumatic causes ⇒ initial stiffness/pain that ↓ over a few hrs
      • Disc stiffness ⇒ ↓ after 20-30 mins
      • Spinal stenosis ⇒ ↑ with activity
  • Aggravating Factors
    • Valsalva, coughing or bending forward ⇒ ↑ pain with disc herniation
    • Worse with walking downhill or downstairs ⇒ spinal stenosis
  • Relieving Factors
    • Prescription or OTC meds tried
    • Positions that decrease pain
  • Psychosocial Factors
    • Assess how pain is affecting patient’s lifestyle
    • Beliefs about prognosis/any litigation or disability issues
  • Associated Symptoms
    • Red flag symptoms
    • Urinary, gynecologic or abdominal symptoms ⇒ ? visceral pathology
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14
Q

LBP

Red Flags

A
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15
Q

LBP

Physical Exam

A
  • Inspect:
    • Posture
    • Curvatures
    • Spinous processes
    • Paraspinous muscles
  • Palpate:
    • Spinous processes/paraspinous muscles
  • Range of motion of lumbar spine
    • Flexion
    • Extension
    • Lateral bending
    • Rotation
    • Any movement worsen pain?
  • Neurologic exam
  • Abdominal exam, pelvic or prostate exam as indicated
  • Special tests ⇒ SLR
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16
Q

LBP

Neurologic Exam

A
  • Motor strength:
    • Look for asymmetry
    • Grade on scale of 0-5
      • Full ROM against gravity w/ max resistance (5)
      • Full ROM against gravity w/ some resistance (4)
      • Full ROM against gravity w/ no resistance (3)
      • Full ROM with gravity eliminated (2)
      • Partial ROM with gravity eliminated (1)
      • No movement detected (0)
  • Deep tendon reflexes
    • Patellar tendon reflex (knee jerk) – mainly L4
    • Achilles reflex (ankle jerk) – mainly S1
  • Sensation
17
Q

Straight Leg Raise Test

(SLR)

A
  • Performed w/ pt supine
  • Test if radicular pain occurs when leg is passively elevated to 30-60°
  • Sensitive for root compression
    • Compressed nerve root is stretched producing radicular pain
  • Not very specific
  • Positive if maneuver causes pain to radiate down leg
    • Not if it increases back pain
18
Q

Crossed SLR

A

Positive if raising “good” leg causes pain radiating down the affected leg

More specific for herniated disc

Less sensitive than SLR

19
Q

Acute Low Back Pain

Evaluation

A
  • No red flag from H&P
    • Conservative Rx for up to 6 weeks
      • Pain meds, muscle relaxants, and pt education
    • No imaging
    • Not Bedrest ⇒ ↑ deconditioning / doesn’t ↓ pain
    • Re-evaluate in 6 weeks
      • Sooner for worsening pain or neuro symptoms
    • Improved ⇒ f/u and prevention
    • Not improved ⇒ begin imaging
      • Usually start w/ plain films then MRI or CT/bone scan if needed
      • Labs: CBC, ESR, CRP
  • Red flag from H&P
    • Begin dx eval w/ plain films & lab tests
    • Consider advanced imaging (MRI usually)
    • Surgical eval if spinal pathology present
20
Q

Acute Low Back Pain

Recommendations

A

Evidence-based recommendations from ACP & APS:

  • Routine imaging does not improve clinical outcomes & exposes patients to unnecessary harms
  • Presence of imaging abnormalities ≠ pain etiology
    • MRI in asymptomatic adults show herniated discs in 30-40% and degenerative changes in 90%
  • High cost low back pain expenditures in US
    • Direct cost of procedure
    • Additional testing ordered for f/u of initial testing result, referrals, procedures
    • Lost days from work
21
Q

Back Pain

Surgical Indications

A
  • Clear indications:
    • Cauda equina syndrome
    • Gross motor weakness
    • Progressive neuro signs/symptoms
  • Elective indication:
    • Pt preference
    • Pts w/ disc herniation and radicular pain usually recover w/ or w/o surgery
      • Surgery vs conservative care
        • Better pain & function at 12 wks w/ surgery
        • No difference at 52 wks
22
Q

Chronic Low Back Pain

Risk Factors

A
  • Depressed mood
  • Poor coping strategies
  • Somatization
  • Psychosocial Distress
  • Workers compensation or litigation claims
23
Q

Chronic Low Back Pain

Management

A
  • Often difficult for patient, family and employer
    • Longer time off work/disable ⇒ more likely to never return to work
  • Treatment goals:
    • Optimize function
    • Decrease pain
    • Prevent chronic narcotic use
  • Multidisciplinary approach:
    • NSAIDs
    • Core exercises
    • Antidepressant drugs
    • Consider massage / acupuncture / yoga
24
Q

LBP

Conclusions

A
  • Most cases of acute low back pain are self-limited and do not require imaging
    • Responds to conservative treatment
  • Need to take a careful hx including onset, exacerbating and relieving factors and perform a thorough spine and neuro exam to determine cause
  • Remember the red flags to consider in the evaluation of back pain

4. HDS Multisystem (43 decks)

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