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LMCC Part II > Chronic Back Pain > Flashcards

Chronic Back Pain Flashcards

1
Q

what are the two most important factors for delineating the source of lower back pain (mechanical vs non mechanical)

A

physical exam and focused neuro-muscular exam

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2
Q

what are the 4 broad categories of low back pain

A

mechanical (80-90%)

neurogenic (5-15%)

non mechanical (1%)

visceral disease

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3
Q

list possible causes of mechanical back pain

A
  1. lumbar strain/sprain
  2. degenerative disease
    - -spondylosis (discs)
    - -osteoarthritis
  3. spondylolithesis
  4. osteoporosis
  5. fractures
    - -osteoporotic
    - -traumatic
  6. congenital disease
    - -severe kyphosis
    - -scoliosis
  7. spondylosis
  8. facet joint asymmetry
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4
Q

list some causes of neurogenic low back pain

A
  1. herniated disc
  2. spinal stenosis
  3. osteophytic nerve root compression
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5
Q

what are the 5 broad categories/types of non mechanical back pain

A
  1. neoplasia
  2. infection
  3. inflammatory arthritis
  4. Scheuermann disease (osteochondrosis)
  5. Pagets disease
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6
Q

what types of neoplasm should you be aware of in back pain

A 
multiple myeloma
lymphoma and leukemia
spinal cord tumours
retroperitoneal tumours
metastatic carcinoma
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7
Q

what types of infection should you be aware of in back pain

A 
osteomyelitis
septic discitis
paraspinous abscess
epidural abscess
bacterial endocarditis
herpes zoster
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8
Q

what types of inflammatory arthritis should you be aware of in back pain

A

ankylosing spondylitis
psoriatic spondylitis
reactive arthritis
inflammatory bowel disease

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9
Q

what types of organs/visceral disease can cause back pain

A
  1. pelvic organs
    - -prostatitis
    - -endometriosis
    - -chronic PID
  2. renal disease
    - -nephrolithiasis
    - -pyelonephritis
    - -perinephritic abscess
  3. AAA
  4. GI disease
    - -pancreatitis
    - -cholecystitis
    - -penetrating ulcer
  5. fat herniation of lumbar spine
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10
Q

timelines of acute, subacute, and chronic back pain

A

acute
subacute is less than 12 weeks
chronic is more than 12 weeks

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11
Q

what does morning stiffness suggest in back pain

A

OA

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12
Q

what does constant pain at night suggest back pain

A

neoplasm, infection or inflammation

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13
Q

what to ask about on HPI specifically for back pain

A

associated symptoms like fever, weight loss, bowel/bladder/sexual dysfunction

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14
Q

red flags for back pain

A

cauda equina syndrome

severe worsening pain at night or when lying down (more than 2-6 weeks)

weight loss, hx cancer, fever

use of steroids or IV drugs

patient with first episode above age 50 (malignancy risk)

widespread neurological signs

significant trauma

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15
Q

what is cauda equina syndrome

A

sudden loss of bowel/bladder control, saddle anesthesia, bilateral leg weakness and numbness

*surgical emergency

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16
Q

what to ask specifically on back pain ROS

A

previous history aortic aneurysm

dysuria
frequency/urgency of urination
bladder and bowel retention/incontinence

rash
morning stiffness

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17
Q

“yellow” flags for back pain (risk factors)

A 
age
smoking
substance use/IVDU
obesity
female gender
psychosocial barriers
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18
Q

in addition to an MSK and neuro exam, what other exam can be helpful in back pain

A

abdo exam, to rule out visceral disease

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19
Q

describe the inspection portion of the lumbar back exam for back pain

A

check for skin markings, dimples, scars, deformities or swelling

inspect for lordosis, kyphosis, scoliosis

look at gait

look at total spinal posture (inability to walk heel to toe and squat and ride indicates cauda equina or neurological compromise)

20
Q

describe the palpation portion of the lumbar exam for back pain

A

palpate for VERTEBRAL TENDERNESS (mets/infection/fracture)

also check for altered temp, muscle spasms, paravertebral muscles

with patient supine–> palpate umbilicus, inguinal areas, iliac crests, symphysis pubis

with patient prone–> palpate spinous processes, sacrum, SI joints, coccyx, iliac crests, ischial tuberosities

21
Q

what you do look for on ROM testing for back pain

A

pain with forward flexion–> mechanical etiology

pain with extension–> spinal stenosis

also look at side flexion, rotation, chest expansion

22
Q

list the special tests for lumbar pain/back pain

A

Schober’s test (lumbar flexion)

straight leg raise

cross straight leg

Bragard’s test

Prone straight leg

Patrick test

23
Q

what is Schober’s test

A

looks at lumbar flexion

mark 10 cm above and 5 cm below dimples of Venus

should increase to 20 cm or more during flexion

get limited flexion in ankylosing spondylitis

24
Q

what is straight leg raise test

A

raise leg until radicular pain felt

positive if pain in sciatic L4-S3 at 30-70 degrees passive flexion (indicates radiculopathy)

25
Q

what is the cross straight leg test

A

raise asymptomatic extremity in similar fashion to straight leg test

positive if pain occurs on contralateral side (indicates radiculopathy)

26
Q

what is Bragard’s test

A

if pain is generated with a straight leg raise, lower the symptomatic extremity until the pain disappears. then, dorsiflex the ankle at the point when the pain disappears to reproduce pain

this test is positive in cases of lesions in lumbosacral, SI joint or hamstring regions (L4-S1)

27
Q

what is the prone straight leg raise test

A

with extension of extremity, if pain moves more anteriorly in the thigh, its likely L2, L3

28
Q

what is patrick test

A

SI joint pain

FABER–> flexion, abduction, external rotation

29
Q

what neuro exam should be done in low back pain

A

full neuro exam of the lower limbs, including sensation, strength, reflexes

30
Q

if the lesion is in L1, how do the following aspects present:

  1. pain
  2. sensory loss
  3. weakness
  4. stretch reflex loss
A

pain–inguinal
sensory loss–inguinal
weakness–rarely hip flexion
stretch reflex loss–none

31
Q

if the lesion is in L2-4, how do the following aspects present:

  1. pain
  2. sensory loss
  3. weakness
  4. stretch reflex loss
A

pain–back, radiating into anterior thigh or medial lower leg

sensory loss–anterior thigh, occasionally medial lower leg

weakness–hip flexion and adduction, and knee extension

stretch reflex loss–patellar tendon

32
Q

if the lesion is in L5, how do the following aspects present:

  1. pain
  2. sensory loss
  3. weakness
  4. stretch reflex loss
A

pain–back, radiating into buttock, lateral thigh, lateral calf, dirsum foot, great toe

sensory loss–lateral calf, dorsum foot, web space between first and second toe

weakness–hip abduction, knee flexion, foot dorsiflexion, toe extension/flexion, foot inversion/eversion

stretch reflex loss–internal hamstrings tendon

33
Q

if the lesion is in S1, how do the following aspects present:

  1. pain
  2. sensory loss
  3. weakness
  4. stretch reflex loss
A

pain–back, radiating into buttock, lateral/posterior thigh, posterior calf, lateral/plantar foot

sensory loss–posterior calf, lateral/plantar aspects of foot

weakness–hip extension, knee flexion, plantar flexion of foot

stretch reflex loss–achilles

34
Q

if the lesion is in S2-4, how do the following aspects present:

  1. pain
  2. sensory loss
  3. weakness
  4. stretch reflex loss
A

pain–sacral or buttock pain radiating into posterior aspect of leg/perineum

sensory loss–medial buttock, perineal, perianal

weakness–possible urinary and fecal incontinence, sexual dysfunction

stretch reflex loss–bulbocavernosus, anal wink

35
Q

what blood tests should you order if thinking of Pagets disease

A

calcium and phosphate

36
Q

what should you order if suspect multiple myeloma

A

albumin
serum or urine electrophoresis
(SPEP/UPEP)

37
Q

when should you order a lumbar spine XR in back pain

A

pain more than 6 weeks or red flags

38
Q

when would you consider a bone scan in back pain

A

if considering infection or malignancy

39
Q

when would you order a skeletal survey in back pain

A

multiple myeloma

40
Q

what blood tests should be done to workup possible PMR

A

rheumatoid factor and/or anti-CCP antibodies

CRP or ESR

bone profile including calcium and ALP

41
Q

first line pain management for acute and subacute back pain

A

acetaminophen

alternating cold and heat

physiotherapy and exercise

42
Q

second line pain management for acute and subacute back pain

A

NSAIDs

can also add cyclobenzaprine for muscle spasms

can consider controlled release opioid

43
Q

in what time frame should mechanical back pain resolve

A

less than 6 weeks

44
Q

third line management for chronic back pain

A

first and second line is same as acute

third line is TCA
4th–tramadol
5th–strong, controlled release opioids

45
Q

in what situations should you consider XRAY immediately

A 
constitutional sx
risk of infection
cancer history
hx traumatic onset
less than 18 or older than 50 years
osteoporosis
focal neuro deficit
progressive or disabling symptoms
duration longer than 6 wks
46
Q

should patients without radicular symptoms be offered steroid injections

A

no

LMCC Part II (52 decks)

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