back pain Jaynstein Flashcards
Whats considered acute LBP?
acute is <4 week
What is subacute LBP?
4-12 weeks
What is chronic LBP?
> 12 weeks
~20weeks of pts will into chronic
What are the RF of developing chronic LBP?
- Psychosocial factors are the strongest predictor
- Congenital spine abnormalities
- Smoking
- Occupation
- Prior episode of LBP
- Physical unfitness
- Increasing age
What are the red flags of backpain?
TUNA FISH
What are important of history question for backpain?
All of oldcaarts
- prior h/o same
- history of IVDU
- systemic infection
- loss of bowel/bladder control but urinary retention to urinate is bad sign!
- Any Chiropractic manipulation?
What are signs of cancer?
- 50 years old
- H/o of CA, possible for metastic dz
- Breast, lung and prostate for metastasize to spine/bone
- weight loss
- Pain more than 1 month duration
- Failure to improve conservative therapy
- Pain with unrelieved with rest (at night
What is the workup for CA in back?
CBC, plain films, direct to possible source
Spinal infection comes from?
Urinary infection, indwelling cathers, skin infection and IVDU
T/F Fever is sensitive for spinal infxn
False, not sensitive
What is the most sensitive for spinal infection?
Spinal tenderness
What is the workup for spinal infection?
- ua, cbc, blood cultures, lactate
- ESR is the most sensitive and specific lab
- MRI wwo imaging study of choice
Compression fracture is most often occurs in patients with ___?
Osteoporosis
T/F Pts on long-term corticosteroid therapy have a compression fx until proven otherwise
True
If you think pt has compression fracture, what is the 1st dx imaging?
Plain film
T/F If pt has + fracture then you dont need to get a CT
True, if pt has negative xray then get a CT w.o contrast to r/o fracture
What is the treatment for compression fracture?
Kyphoplasty/Vertebroplasty
what are the characteristics of ankylosing spondylitis?
- Morning stiffness
- Improvement with exercise
- Onset of pain at age < 40
- Pain progression, slowly
- Pain > 3 months
Whats the most important indicator in AS?
reduced flexion
What is + in majority of AS?
HLA-B27
Whats the next thing you should x-ray?
Pelvic Xray
(Bilateral and symmetric sacroilitis) because they have scral changes first before the back
Whats the next thing you should x-ray after sacral?
lumbar spine
- Bone sclerosis
- Bamboo sign is present in <10% patients
Lumbar disc hernation
- Have sciatica
- Don’t need surgery
- H/o of recurrent LBP prior to sciatica
What is the most sensitive test for disc herniation?
SLR
and positive crossed straight leg raise
(other side with no pain will cause pain on the effected side)
Positive SLR and CSLR
Less concerning bc its expected with disc herniation.
if its with neuro defecits, then its concerning.
What are physical findings for lumbar disc herniation?
- Ankle dorsiflexion weakness, great toe extensor weakness, and decreased pinprick sensation are also clinically helpful
T/F lumbar spine imaging studies will reveal an asymptomatic anatomic disc herniation
True
When should you order MRI?
After 6 weeks after doing conservative symptoms.
If they have more neuro syms earlier then order the dx imaging early
What is Spinal stenosis
Narrowing of the spinal canal leads to nerve impingement /cord compression
Spinal stenosis sx
pain in the legs, and sometimes neuro deficits, that occurs after standing or walking
How can you differentiate spinal stenosis from PVD?
check pulses, PVD will have decreased pulse
What is the average age surgical intervention for spinal stenosis?
age 55 and with 4 years of symptoms
T/F Spinal stenosis pain is provoked by bike riding
False, it does not cause pain when riding a bike
How does spinal stenosis progress?
Back pain slowly progresses to constant pain with leg “stiffness” or pain
T/F Pain in increased with spine flexion for spinal stenosis?
false, it is increased with spine extension
Whats the imaging for spinal stenosis?
L-spine
or
MRI or CT L/S WO contrast
What is cauda equina?
Massive midline disc herniation leading to spinal cord compression
Is cauda equina emergency?
YES YES
What is a factor for cauda equina?
disc herniation!!
Signs for cauda equina?
- Urinary retention (loss of bowel/bladder but LATE)
- Anesthesia (saddle region anesthesia)
- Decreased rectal tone (
- Sciatica
- +SLR
- Sensory and motor deficits
What is the next step for Cauda Equina?
- Emergent MRI
- Emergent Neurosurgery consult
T/F is a good H&P does not cause any concerns for any of the backpain then no additional workup is required
TRUE
T/F No imaging or other diagnostic tests are needed initially in a patient with nonspecific low back pain.
True
When should you obtain spine imaging?
high risk pt with vertebral compression fracture
- infection, cauda equina syndrome, progressive/severe neuro deficits
- Risk factors for cancer
- Radiculopathy or spinal stenosis
- with progressive neuro symptoms with NO improvement after >6weeks.
What labs should you consider?
- ESR
- CBC (maybe if they have infection or cancer)
- Lactate, blood culture (maybe if they have infection or cancer)
Treatment for LBP?
Active
- PT, massage, acupuncture, manipulation
What is pharm treatment for LBP?
- Combo active therapy with meds
- first-line is NSAIDs or APAP
- Second line muscle relaxers or antidepressants
What about other treatment of LBP?
- Topical meds
- Trigger point injection
- Nerve pain
What should you avoid with LBP treatment
Benzo’s and opiates
Benzo’s are potent muscle relaxers, possible to do one dose of benzo (valium) to help relax/decrease pain to continue oral meds.
What is goal for LBP?
- Try to get back to baseline in 4 weeks
- Walk 20min, 3-4 times a week
- Re-eval in 4 weeks, sooner if uncontrolled pain, progressive symptoms
- ER precaution
