Evaluating Lower back pain in Primary care-jaynstein-FINAL Flashcards
Epidemiology: LBP
What conditions MUST be r/o? (all of these are rare)
- 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%
LBP:
- who does it affect?
- Peaks at ____yo
- affects all ages
- *Peaks at 55 to 64 yo
The MCC of activity limitation in persons <45 years of age
Trends in LBP:
-increased utilization of ______
- imaging studies, incidence of surgery, use of injections, prescription of opioids, and increased costs for LBP
- NO DECREASE in disability**
Goals for PCP providers:
- Prevention of disability is the primary goal!
- Find the small (small!) % of patients who have an emergent cause of their back pain
Acuity of LBP:
acute= _____ weeks,
-approx. ___% of Pts will progress into chronic pain
Acute: <4 weeks
Subacute: 4-12 weeks
Chronic: >12 weeks; approx. 20% of pts will progress into chronic
Risk factors for developing Chronic LBP: list Ex’s
**Psychosocial factors are the strongest predictor
- Congenital spine abnormalities
- Smoking
- Occupation
- Prior episode of LBP
- Physical unfitness
- Increasing age
Red flags of backpain:
TUNAFISH
- trauma
- unexplained weight loss
- neurologic Sx
- Age >50
- fever
- IV drug use
- Steroid use
- Hx of CA
Important history questions for Pts:
ALL of OLDCARTS plus _____
- 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)
Should I work-up my LBP patient? (2 questions)
- Do I think there is a serious systemic cause of the patients pain?
- Is there neurological compromise that may require surgical intervention?
S/Sx of a metastatic process causing LBP (Cancer S/Sx)
**Unexplained weight loss, pain > 1 month duration, failure to improve with conservative therapy, and pain unrelieved with rest (night time pain)
Metastatic Process (CA) work-up
- labs?
- imaging?
Work-up – CBC, plain films, direct to possible source
Cancer accounts for less than ___% of pts who present to PC for eval of LBP
1%
Cancer:
___% of these patients are over 50 years old
-A patient with a h/o CA who presents with LBP is ______
80%
**metastatic disease until proven otherwise
What are the MC primary CAs that metastasize to spine/bone?
breast, lung and prostate most common primary that metastasize to spine/bone
40% of spinal infections come from: ______
urinary infection, indwelling catheters, skin infection, and IVDU
T/F: Fever is not sensitive for a spinal infection
True. Fever IS NOT sensitive (40% overall)
- 83% in epidural abscess
- 50% in pyogenic osteomyelitis
- 27% in TB osteomyelitis
What symptom is sensitive and specific for a spinal infection?
Spinal tenderness is 86% sensitive and 60% specific
Spinal infection: work-up
Labs? What is the most sensitive lab?
UA, cbc, blood cultures, lactate
**ESR is the most sensitive and specific lab
Spinal infection: work-up
Imaging study of choice?
MRI w and wo contrast= study of choice
–Need contrast to find an abscess, without contrast helps to evaluate the bone
Compression fractures most often occur in Pts with _______
osteoporosis (systemic)
**Caucasian women over 70 yo
___% of compression fx’s will be atraumatic
30%
Pts on long-term corticosteroid therapy with LBP have a ______ fracture until proven otherwise
compression
Compression fx: work-up
imaging?
- Plain films (XR)
- -If negative consider CT wo
When is kyphoplasty indicated for tx of a compression fracture?
- when there is a loss of >50% of height**
- Acute = better outcomes
ankylosing spondylitis: S/Sx
-4 out of 5 of the following criteria is 85% sensitive for the dx, but NOT specific
- Morning stiffness
- Improvement with exercise
- Onset of pain at age < 40
- Pain progression, slowly
- Pain > 3 months
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
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
What lab value is positive in 95% of ankylosing spondylitis cases?
**HLA-B27
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
Lumbar disc herniation:
___% of Pts with a clinically important disc herniation have sciatica
95%
Lumbar disc herniation:
-how many pts will need surgery?
2%–very low
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
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….
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
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.
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
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
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
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)
spinal stenosis=
Narrowing of the spinal canal leads to nerve impingement /cord compression
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
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)
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)
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%
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
What test should be emergently ordered for a cauda equina suspect?
- *emergent MRI
- emergent neurosurgeon consult
Are imaging/other diagnostic tests needed for initial work-up in a Pt with LBP?
NO imaging or other diagnostic tests are needed initially
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
Are any labs helpful in the evaluation of LBP?
- **ESR (good for r/o spine infections)
- CBC
- lactate, blood cultures
What imaging and labs are sufficient in the majority of Pts with LBP?
Initial work-up of plain films and an ESR is sufficient
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!
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
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
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)
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
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
