Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Clinical Decision Making II-Fall 21' > Evaluating Lower back pain in Primary care-jaynstein-FINAL > Flashcards

Evaluating Lower back pain in Primary care-jaynstein-FINAL Flashcards

1
Q

Epidemiology: LBP

What conditions MUST be r/o? (all of these are rare)

A
  • ankylosing spondylitis 0.3% to 5%
  • compression fracture 4%
  • symptomatic herniated disc 4%
  • Spinal stenosis 3%
  • Cancer 0.7%
  • Cauda equina syndrome 0.04%
  • spinal infection 0.01%
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

LBP:

  • who does it affect?
  • Peaks at ____yo
A
  • affects all ages
  • *Peaks at 55 to 64 yo

The MCC of activity limitation in persons <45 years of age

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Trends in LBP:

-increased utilization of ______

A
  • imaging studies, incidence of surgery, use of injections, prescription of opioids, and increased costs for LBP
  • NO DECREASE in disability**
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Goals for PCP providers:

A
  • Prevention of disability is the primary goal!

- Find the small (small!) % of patients who have an emergent cause of their back pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Acuity of LBP:
acute= _____ weeks,

-approx. ___% of Pts will progress into chronic pain

A

Acute: <4 weeks
Subacute: 4-12 weeks
Chronic: >12 weeks; approx. 20% of pts will progress into chronic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Risk factors for developing Chronic LBP: list Ex’s

A

**Psychosocial factors are the strongest predictor

  • Congenital spine abnormalities
  • Smoking
  • Occupation
  • Prior episode of LBP
  • Physical unfitness
  • Increasing age
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Red flags of backpain:

TUNAFISH

A
  • trauma
  • unexplained weight loss
  • neurologic Sx
  • Age >50
  • fever
  • IV drug use
  • Steroid use
  • Hx of CA
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Important history questions for Pts:

ALL of OLDCARTS plus _____

A
  • Prior h/o same? What work-up did you have? What helped the most? Is this episode different?
  • History of IVDU?
  • Any systemic infectious complaints? Fever, body aches, flu-like syndrome
  • Not only loss of bowel or bladder control, but assess for urinary retention
  • Any chiropractic manipulation? (more so for cervical pain than LBP)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Should I work-up my LBP patient? (2 questions)

A
  1. Do I think there is a serious systemic cause of the patients pain?
  2. Is there neurological compromise that may require surgical intervention?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

S/Sx of a metastatic process causing LBP (Cancer S/Sx)

A

**Unexplained weight loss, pain > 1 month duration, failure to improve with conservative therapy, and pain unrelieved with rest (night time pain)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Metastatic Process (CA) work-up

  • labs?
  • imaging?
A

Work-up – CBC, plain films, direct to possible source

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Cancer accounts for less than ___% of pts who present to PC for eval of LBP

A

1%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Cancer:
___% of these patients are over 50 years old

-A patient with a h/o CA who presents with LBP is ______

A

80%

**metastatic disease until proven otherwise

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are the MC primary CAs that metastasize to spine/bone?

A

breast, lung and prostate most common primary that metastasize to spine/bone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

40% of spinal infections come from: ______

A

urinary infection, indwelling catheters, skin infection, and IVDU

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

T/F: Fever is not sensitive for a spinal infection

A

True. Fever IS NOT sensitive (40% overall)

  • 83% in epidural abscess
  • 50% in pyogenic osteomyelitis
  • 27% in TB osteomyelitis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What symptom is sensitive and specific for a spinal infection?

A

Spinal tenderness is 86% sensitive and 60% specific

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Spinal infection: work-up

Labs? What is the most sensitive lab?

A

UA, cbc, blood cultures, lactate

**ESR is the most sensitive and specific lab

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Spinal infection: work-up

Imaging study of choice?

A

MRI w and wo contrast= study of choice

–Need contrast to find an abscess, without contrast helps to evaluate the bone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Compression fractures most often occur in Pts with _______

A

osteoporosis (systemic)

**Caucasian women over 70 yo

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

___% of compression fx’s will be atraumatic

A

30%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Pts on long-term corticosteroid therapy with LBP have a ______ fracture until proven otherwise

A

compression

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Compression fx: work-up

imaging?

A
  • Plain films (XR)

- -If negative consider CT wo

24
Q

When is kyphoplasty indicated for tx of a compression fracture?

A
  • when there is a loss of >50% of height**

- Acute = better outcomes

25
ankylosing spondylitis: S/Sx | -4 out of 5 of the following criteria is 85% sensitive for the dx, but NOT specific
1. Morning stiffness 2. Improvement with exercise 3. Onset of pain at age < 40 4. Pain progression, slowly 5. Pain > 3 months
26
But, AS is so rare, that a study of this found only __ of 367 ppl with a positive screen had AS. A predictive value of 0.04.
16
27
ankylosing spondylitis: - cornerstone is _______ - MC in men or women? - uncommon in which PT populations?
**reduced flexion--but this is not specific - 3 men:1 woman - Uncommon in AA, American Indians, and Japanese
28
What lab value is positive in 95% of ankylosing spondylitis cases?
**HLA-B27
29
Ankylosing Spondylitis: -imaging study? specific findings?
Pelvic Xray: shows Bilateral and symmetric sacroilitis - Plain films of the lumbar spine: - -Bony sclerosis - -**Bamboo sign is present in <10% of patients
30
Lumbar disc herniation: | ___% of Pts with a clinically important disc herniation have sciatica
95%
31
Lumbar disc herniation: -how many pts will need surgery?
2%--very low
32
Lumbar disc herniation: - MOST pts have a hx of recurrent LBP prior to _____ - peaks at age ____
- **sciatica - With an acute, frank herniation, **leg pain often overshadows back pain --Peak: 30-55yo
33
For a lumbar disc herniation, which test is 80% sensitive and 40% specific?
-SLR --**With the addition of a positive Crossed SLR (CSLR)– 90% sensitive (only 25% specific though!) Make sure you’re doing it right….
34
Describe the SLR test
Test symptomatic side - Tension isn’t transmitted to the nerve roots (L4-S2, L5/S1 most sensitive thou) until 30 degrees. After 60 degrees of stretch, further movement of the nerves is negligible. - +SLR= Pt has increased pain btw 30-60 deg only
35
Describe the Crossed SLR
- examiner raises straight leg 30-60 degrees--> eliciting radicular pain on the **opposite side - -sensitivity: 25% - specificity: 90-97% Test ipsilateral (pain-free) leg. Elicits pain in the symptomatic leg.
36
Interpreting a +SLR
Positive SLR= Pain b/w 30-60 degrees, the lower the degree at pain onset the more specific the test is and the larger the disc protrusion -**Most sensitive for L5/S1 -**Positive SLR and CSLR is very specific and sensitive
37
Is there neurological compromise that may require surgical intervention for a lumbar disc herniation? (what PE findings will be present)
- Findings of ankle dorsiflexion weakness, great toe extensor weakness, and decreased pinprick sensation are also clinically helpful - Use PE findings in combination– impaired ankle reflex + weak dorsiflexion is found in 90% of Pts who have surgical herniation's
38
What % of herniated discs are asymptomatic? do these Pts need further tx?
- 20-30% of lumbar spine imaging studies will reveal an asymptomatic anatomic disc herniation - IF asymptomatic--> they do not need further work-up, tx, or referral **Only 2% of pts with a symptomatic disc herniation undergo surgery
39
For a Pt with a suspected lumbar disc herniation, what is the imaging test of choice?
* *MRI without contrast is test of choice*** - Significant PE findings: looking for the 2% who need surgical intervention, not truly to dx - **Pain or symptoms > 6 weeks (Pain >6 weeks is the cut off, failed conservative tx’s, and tried PT)
40
spinal stenosis=
Narrowing of the spinal canal leads to nerve impingement /cord compression
41
Spinal stenosis can lead to neurogenic claudication. List Sx assoc. w/ neurogenic claudication
* *pain in the legs, +/- neuro deficits, that occurs after standing or walking - Differentiate from PVD– by checking pulses -Average age at surgical intervention is **55 with 4+ years of symptoms
42
Spinal Stenosis causes back pain that slowly progresses to _______ . - pain is NOT provoked by _______ - pain is increased with _______
constant pain with leg “stiffness” or pain ***Pain NOT provoked by bike riding & increased with **spine extension (flexion is usual with other causes)
43
Spinal stenosis: | imaging of choice?
- L-spine xray– will show degenerative changes - **MRI or CT L/S WO will diagnose (CT scan CAN NOT tell you if there is impingement of the cord)
44
why is Cauda Equina a neurological emergency?
- EMERGENCY, EMERGENCY, EMERGENCY! - Massive midline disc herniation leading to spinal cord compression - -Occurs in 1-2% of Pts with a disc herniation – true prevalence is 0.04%
45
Cauda equina: Sx?
- Urinary RETENTION--> in 90% - Loss of bowel or bladder sensitive but late! - Anesthesia– buttocks, posterior-superior thigh, or perianal (saddle)– 75% - Decreased rectal tone in 60-80%-MUST do a DRE!!!!!! - Sciatica, +SLR, and sensory and motor deficits all common
46
What test should be emergently ordered for a cauda equina suspect?
* *emergent MRI | - emergent neurosurgeon consult
47
Are imaging/other diagnostic tests needed for initial work-up in a Pt with LBP?
NO imaging or other diagnostic tests are needed initially
48
When to obtain spine imaging (list ex indications)
- High risk for vertebral compression fx - Suspected infection, cauda equina syndrome, progressive/ severe neurologic deficits -Risk factors for cancer: If age is the only risk factor, consider time-limited (1 month) trial of therapy - Suspected radiculopathy or spinal stenosis - In absence of severe/ progressive neuro symptoms with no improvement after >6 weeks, consider MRI
49
Are any labs helpful in the evaluation of LBP?
- **ESR (good for r/o spine infections) - CBC - lactate, blood cultures
50
What imaging and labs are sufficient in the majority of Pts with LBP?
Initial work-up of plain films and an ESR is sufficient
51
EBM TREATMENT OF LBP | -active vs passive therapies?
- **EMPHASIS ON ACTIVE, NOT PASSIVE, THERAPIES - Physical therapy - Massage therapy - Acupuncture - Manipulation - **Bed rest has shown less favorable outcomes!
52
EBM TREATMENT OF LBP: | -first line tx?
-Combine active therapies with pharmacological therapies First line: nsaids or apap -->Neither appears superior and combo of two has not demonstrated improved outcomes
53
EBM TREATMENT OF LBP: | 2nd line tx?
- Muscle relaxers: Greatest benefit in 1-2 weeks, may last up to 4 weeks. If no sig improvement at 2-4 wks d/c - Antidepressants
54
Which meds should you try to avoid giving Pts for tx of LBP?
- AVOID benzos and opiates - Corticosteroids-->Highly debated– generally not recommended-->? In patients with radicular symptoms (Jaynstein would rather give them a corticosteroid + APAP+ Flexeril than a benzo– for a pt with radicular sx)
55
goals for Pts with LBP: - try to get back to baseline activity in ____ weeks - walk ___ min ___x per week - re-eval in ___ weeks
- 4 weeks - Walk 20 minutes 3-4x/week - Re-eval in 4 weeks– sooner if uncontrolled pain, progressive symptoms - Education on ER precautions
56
When should you refer a Pt with LBP?
- Need for urgent or emergent evaluation--> ER - PT--> Earlier better? - Neurosurg--> if unsure of dx, dx made in which an intervention may be deemed helpful or necessary - Pain Management

Clinical Decision Making II-Fall 21' (5 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions