Back Pain and Shoulder Flashcards
What are the 3 categories of back pain?
- nonspecific
- radiculopathy or spinal stenosis
- spinal pathology
What are the symptoms of MSK pain?
aches or cramps radiating across the back like a belt, won’t go past the thigh or hip
What are the symptoms of disc herniation?
radicular pain in a dermatomal distribution and extending below the knee. Exacerbated by valsalva, defecation, or cough.
At what level do 95% of disc herniations occur?
L4-L5 or L5-S1
What suggests L5 impingement?
Pain on the shins and great toe
weak dorsiflexion
What suggests S1 impingment?
Pain on the posterior leg
weakness planter flexion
What symptom makes a straight leg raise positive?
“electric shock” sensation from the hip down
Is the straight leg raise sensitive or specific for herniated disc?
sensitive (91%). Not specific.
Is the CROSSED straight leg raise (raising the UNAFFECTED leg causes pain in the AFFECTED leg) sensitive or specific for herniated disc?
specific (88%). Not very sensitive.
How does spinal stenosis present?
- severe bilateral leg pain.
- “pseudoclaudication”- Not worse with exertion, but is worse with prolonged standing or walking downhill.
- better with sitting
What are “red flags”/alarm symptoms for low back pain?
- History of cancer with new onset back pain
- Weight loss in age>50 yrs old
- Fever or recent infection
- IV drug use
- Urinary retention, incontinence, or fecal incontience, saddle anesthesia (cauda equina syndrome)
- History of osteoporosis, use of steroids (compression fracture)
- Morning stiffness, improvement with exercise, awakening back pain, alternating butt pain (ankylosing spond)
- Leg pain in derm distribution (L4=, L5=anterior leg, S1=posterior leg) and positive straight leg raise test (herniated disc)
- severe bilateral leg pain (spinal stenosis)
there are sensitive but NOT specific, so do NOT automatically warrant bigger evaluation
Rapid progression of neurological deficits is a sign of what?
spinal cord compression
how long do symptoms of back pain have to be present to consider MRI?
a month (4 weeks)
What is cauda equina syndrome?
compression of sacral nerve roots from a tumor or a herniated disc
what PE findings increase suspicion for psychosocial distressors?
- nondermatomal distribution
- pain with passive rotation of the spine
- pain on axial loading (press on head)
- straight leg raise test not positive with distraction
What % of asymptomatic patients who get an MRI have a bulging disk?
60%. So bulging disc doesn’t necessarily mean symptoms.
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?
No. If you think they have one of these things but wouldnt benefit anyways then dont do it
What do you give for spinal cord compression?
High-dose corticosteroids. These provide pain relief and prevent further loss of neurologic function
How do you treat acute low back pain?
acetaminophen
NSAIDs
Not first line:
muscle relaxants (not better than NSAIDs)
opioids (not better than NSAIDs)
gabapentin
How long does back pain have to persist before you refer to surgery?
3 months-2 years (discrepancy in opinion)
How does vertebral osteomyelitis typically present?
- 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)
What vascular pattern does osteomyelitis usually follow?
segmental arteries -> inferior part of one disk, superior part of the adjacent disk -> diskitis
What are sources of hematogenous osteomyelitis?
- IV drug use
- UTI
- URI
- Endocarditis
- IV catheter-related infection
What test should you get for all patients with suspected osteomyelitis?
- Spinal MRI
- Blood cultures (positive in 75% of pts)
Is empiric antibiotic therapy an appropriate first step for suspected osteomyelitis?
No, therapy should be targeted. Must draw blood cultures first.
Is MRI necessary for a suspected disc herniation?
Not necessarily. Only if signs of motor impairment, OR patient not responding to therapy
Three malignancies most commonly associated with spinal cord compression
prostate, breast, and lung cancer
What are late symptoms of spinal cord compression?
back pain, muscle weakness, loss of bowel or bladder control
Empty can test is for what?
Supraspinatus muscle or rotator cuff weakness
Adhesive capsulitis is what?
Seen in patients with immobility (like stroke – hemiplegia on that side). Back and decreased ROM
Football player fell on his shoulder
AC joint sprain
Epileptic patient has arm rotated inwards
X-ray for suspected fracture of humerus I htink
