Back Pain and Shoulder

Question 1

What are the 3 categories of back pain?

Answer 1

1. nonspecific
2. radiculopathy or spinal stenosis
3. spinal pathology

Question 2

What are the symptoms of MSK pain?

Answer 2

aches or cramps radiating across the back like a belt, won’t go past the thigh or hip

Question 3

What are the symptoms of disc herniation?

Answer 3

radicular pain in a dermatomal distribution and extending below the knee. Exacerbated by valsalva, defecation, or cough.

Question 4

At what level do 95% of disc herniations occur?

Answer 4

L4-L5 or L5-S1

Question 5

What suggests L5 impingement?

Answer 5

Pain on the shins and great toe

weak dorsiflexion

Question 6

What suggests S1 impingment?

Answer 6

Pain on the posterior leg

weakness planter flexion

Question 7

What symptom makes a straight leg raise positive?

Answer 7

“electric shock” sensation from the hip down

Question 8

Is the straight leg raise sensitive or specific for herniated disc?

Answer 8

sensitive (91%). Not specific.

Question 9

Is the CROSSED straight leg raise (raising the UNAFFECTED leg causes pain in the AFFECTED leg) sensitive or specific for herniated disc?

Answer 9

specific (88%). Not very sensitive.

Question 10

How does spinal stenosis present?

Answer 10

• severe bilateral leg pain.
• “pseudoclaudication”- Not worse with exertion, but is worse with prolonged standing or walking downhill.
• better with sitting

Question 11

What are “red flags”/alarm symptoms for low back pain?

Answer 11

1. History of cancer with new onset back pain
2. Weight loss in age>50 yrs old
3. Fever or recent infection
4. IV drug use
5. Urinary retention, incontinence, or fecal incontience, saddle anesthesia (cauda equina syndrome)
6. History of osteoporosis, use of steroids (compression fracture)
7. Morning stiffness, improvement with exercise, awakening back pain, alternating butt pain (ankylosing spond)
8. Leg pain in derm distribution (L4=, L5=anterior leg, S1=posterior leg) and positive straight leg raise test (herniated disc)
9. severe bilateral leg pain (spinal stenosis)

there are sensitive but NOT specific, so do NOT automatically warrant bigger evaluation

Question 12

Rapid progression of neurological deficits is a sign of what?

Answer 12

spinal cord compression

Question 13

how long do symptoms of back pain have to be present to consider MRI?

Answer 13

a month (4 weeks)

Question 14

What is cauda equina syndrome?

Answer 14

compression of sacral nerve roots from a tumor or a herniated disc

Question 15

what PE findings increase suspicion for psychosocial distressors?

Answer 15

• nondermatomal distribution
• pain with passive rotation of the spine
• pain on axial loading (press on head)
• straight leg raise test not positive with distraction

Question 16

What % of asymptomatic patients who get an MRI have a bulging disk?

Answer 16

60%. So bulging disc doesn’t necessarily mean symptoms.

Question 17

If you think a patient probably has a bulging disk/spinal stenosis, but they can’t get an epidural, a steroid injection, surgery, or anything else…do you get an MRI of their back anyways to be sure?

Answer 17

No. If you think they have one of these things but wouldnt benefit anyways then dont do it

Question 18

What do you give for spinal cord compression?

Answer 18

High-dose corticosteroids. These provide pain relief and prevent further loss of neurologic function

Question 19

How do you treat acute low back pain?

Answer 19

acetaminophen
NSAIDs

Not first line:
muscle relaxants (not better than NSAIDs)
opioids (not better than NSAIDs)
gabapentin

Question 20

How long does back pain have to persist before you refer to surgery?

Answer 20

3 months-2 years (discrepancy in opinion)

Question 21

How does vertebral osteomyelitis typically present?

Answer 21

• Back or neck pain gradually worsening over weeks-months
• Fever present in only 50% of pts (and leukocytosis often ABSENT)
• ESR often higher than 100
• Tenderness to palpation over the involved spine
• High risk patient (IV drug use, etc)

Question 22

What vascular pattern does osteomyelitis usually follow?

Answer 22

segmental arteries -> inferior part of one disk, superior part of the adjacent disk -> diskitis

Question 23

What are sources of hematogenous osteomyelitis?

Answer 23

• IV drug use
• UTI
• URI
• Endocarditis
• IV catheter-related infection

Question 24

What test should you get for all patients with suspected osteomyelitis?

Answer 24

• Spinal MRI

- Blood cultures (positive in 75% of pts)

Question 25

Is empiric antibiotic therapy an appropriate first step for suspected osteomyelitis?

Answer 25

No, therapy should be targeted. Must draw blood cultures first.

Question 26

Is MRI necessary for a suspected disc herniation?

Answer 26

Not necessarily. Only if signs of motor impairment, OR patient not responding to therapy

Question 27

Three malignancies most commonly associated with spinal cord compression

Answer 27

prostate, breast, and lung cancer

Question 28

What are late symptoms of spinal cord compression?

Answer 28

back pain, muscle weakness, loss of bowel or bladder control

Question 29

Empty can test is for what?

Answer 29

Supraspinatus muscle or rotator cuff weakness

Question 30

Adhesive capsulitis is what?

Answer 30

Seen in patients with immobility (like stroke – hemiplegia on that side). Back and decreased ROM

Question 31

Football player fell on his shoulder

Answer 31

AC joint sprain

Question 32

Epileptic patient has arm rotated inwards

Answer 32

X-ray for suspected fracture of humerus I htink