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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%
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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

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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**
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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

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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

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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
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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
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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)
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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?
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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)

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11
Q

Metastatic Process (CA) work-up

  • labs?
  • imaging?
A

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

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12
Q

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

A

1%

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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

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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

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15
Q

40% of spinal infections come from: ______

A

urinary infection, indwelling catheters, skin infection, and IVDU

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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
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17
Q

What symptom is sensitive and specific for a spinal infection?

A

Spinal tenderness is 86% sensitive and 60% specific

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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

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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

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20
Q

Compression fractures most often occur in Pts with _______

A

osteoporosis (systemic)

**Caucasian women over 70 yo

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21
Q

___% of compression fx’s will be atraumatic

A

30%

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22
Q

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

A

compression

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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
Q

ankylosing spondylitis: S/Sx

-4 out of 5 of the following criteria is 85% sensitive for the dx, but NOT specific

A
  1. Morning stiffness
  2. Improvement with exercise
  3. Onset of pain at age < 40
  4. Pain progression, slowly
  5. Pain > 3 months
26
Q

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.

A

16

27
Q

ankylosing spondylitis:

  • cornerstone is _______
  • MC in men or women?
  • uncommon in which PT populations?
A

**reduced flexion–but this is not specific

  • 3 men:1 woman
  • Uncommon in AA, American Indians, and Japanese
28
Q

What lab value is positive in 95% of ankylosing spondylitis cases?

A

**HLA-B27

29
Q

Ankylosing Spondylitis:

-imaging study? specific findings?

A

Pelvic Xray: shows Bilateral and symmetric sacroilitis

  • Plain films of the lumbar spine:
  • -Bony sclerosis
  • -**Bamboo sign is present in <10% of patients
30
Q

Lumbar disc herniation:

___% of Pts with a clinically important disc herniation have sciatica

A

95%

31
Q

Lumbar disc herniation:

-how many pts will need surgery?

A

2%–very low

32
Q

Lumbar disc herniation:

  • MOST pts have a hx of recurrent LBP prior to _____
  • peaks at age ____
A
  • **sciatica
  • With an acute, frank herniation, **leg pain often overshadows back pain

–Peak: 30-55yo

33
Q

For a lumbar disc herniation, which test is 80% sensitive and 40% specific?

A

-SLR
–**With the addition of a positive Crossed SLR (CSLR)– 90% sensitive (only 25% specific though!)
Make sure you’re doing it right….

34
Q

Describe the SLR test

A

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
Q

Describe the Crossed SLR

A
  • 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
Q

Interpreting a +SLR

A

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
Q

Is there neurological compromise that may require surgical intervention for a lumbar disc herniation? (what PE findings will be present)

A
  • 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
Q

What % of herniated discs are asymptomatic?

do these Pts need further tx?

A
  • 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
Q

For a Pt with a suspected lumbar disc herniation, what is the imaging test of choice?

A
  • 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
Q

spinal stenosis=

A

Narrowing of the spinal canal leads to nerve impingement /cord compression

41
Q

Spinal stenosis can lead to neurogenic claudication. List Sx assoc. w/ neurogenic claudication

A
  • *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
Q

Spinal Stenosis causes
back pain that slowly progresses to _______ .

  • pain is NOT provoked by _______
  • pain is increased with _______
A

constant pain with leg “stiffness” or pain
***Pain NOT provoked by bike riding

& increased with **spine extension (flexion is usual with other causes)

43
Q

Spinal stenosis:

imaging of choice?

A
  • 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
Q

why is Cauda Equina a neurological emergency?

A
  • 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
Q

Cauda equina: Sx?

A
  • 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
Q

What test should be emergently ordered for a cauda equina suspect?

A
  • *emergent MRI

- emergent neurosurgeon consult

47
Q

Are imaging/other diagnostic tests needed for initial work-up in a Pt with LBP?

A

NO imaging or other diagnostic tests are needed initially

48
Q

When to obtain spine imaging (list ex indications)

A
  • 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
Q

Are any labs helpful in the evaluation of LBP?

A
  • **ESR (good for r/o spine infections)
  • CBC
  • lactate, blood cultures
50
Q

What imaging and labs are sufficient in the majority of Pts with LBP?

A

Initial work-up of plain films and an ESR is sufficient

51
Q

EBM TREATMENT OF LBP

-active vs passive therapies?

A
  • **EMPHASIS ON ACTIVE, NOT PASSIVE, THERAPIES
  • Physical therapy
  • Massage therapy
  • Acupuncture
  • Manipulation
  • **Bed rest has shown less favorable outcomes!
52
Q

EBM TREATMENT OF LBP:

-first line tx?

A

-Combine active therapies with pharmacological therapies

First line: nsaids or apap
–>Neither appears superior and combo of two has not demonstrated improved outcomes

53
Q

EBM TREATMENT OF LBP:

2nd line tx?

A
  • 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
Q

Which meds should you try to avoid giving Pts for tx of LBP?

A
  • 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
Q

goals for Pts with LBP:

  • try to get back to baseline activity in ____ weeks
  • walk ___ min ___x per week
  • re-eval in ___ weeks
A
  • 4 weeks
  • Walk 20 minutes 3-4x/week
  • Re-eval in 4 weeks– sooner if uncontrolled pain, progressive symptoms
  • Education on ER precautions
56
Q

When should you refer a Pt with LBP?

A
  • 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)

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