Evaluation of Back Pain in PC (final) Flashcards
>___% of pts who present to PC have LBP that cannot be attributed to a specific dz or spinal pathology.
>85% of pts who present to PC have LBP that cannot be attributed to a specific dz or spinal pathology.
A pt presents to PC with LBP. Which conditions must be ruled out?
Hint: there are 7 and they are all rare.
- Ankylosing spondylitis (0.3% to 5%)
- Compression fx (4%)
- Symptomatic herniated disc (4%)
- Spinal stenosis (3%)
- Cancer (0.7%)
- Cauda equina syndrome (0.04%)
- Spinal infection (0.01%)
*The last 2 are why we get sued
T/F: There have been upward trends in utilization of imaging studies, incidence of surgery, use of injections, Rx opioids, and costs, which have all been absolutely fantastic for decreasing disability due to LBP!
Nope. None of that sh*t is working.
What are the goals for PC providers with LBP?
- Prevention of disability is the primary goal!
- Find the small (small!) percentage of pts who have an emergent cause of back pain
Acute back pain is how many weeks?
<4 wks
Subacute back pain is how many weeks?
4-12 wks
Chronic back pain is how many weeks?
>12 wks
What percentage of back pain pts will progress into chronic back pain?
Approx 20%
Name some risk factors for developing chronic LBP
- Physiologic factors are the strongest predictors
- Congenital spine abnormalities
- Smoking
- Occupation
- Prior episode of LBP
- Physical unfitness
- Increasing age
What are the red flags of back pain?
*Jaynstein emphasized this slide*
- Trauma
- Unexplained wt loss
- Neurologic sx
- Age >50
- Fever
- IVDU
- Steroid use
- Hx of cancer
LBP stinks more than tunafish
We’re usually pretty good at asking about loss of bowel/bladder, but this is usually a late finding of cord injury. What is an early sign of cord injury that we should also be asking about?
Urinary retention
Cancer accounts for ___% of pts who present to PC for eval of LBP
<1%
A pt with PMH of cancer presents with LBP is ____________ until proven otherwise
Metastatic disease
Most common primary cancers to metastasize to spine/bone include….
Breast, lung, prostate
Pt presents with night time pain in back. You should immediately think of _______ and your workup should include ____________________________.
Pt presents with night time pain in back. You should immediately think of cancer and your workup should include CBC, plain films, direct to possible source.
Fever + back pain = ___________ until proven otherwise
Spinal abscess
40% of spinal infections come from ____________, _____________, ____________, and ____________.
- Urinary infection
- Indwelling catheter
- Skin infection
- IVDU
T/F: Fever is sensitive for diagnosing spinal infections
False. Only 40% overall:
- 83% in epidural abscess
- 50% in pyogenic osteomyelitis
- 27% in TB osteomyelitis
T/F: Spinal TTP is sensitive for spinal infection
True. Spinal TTP is 86% sensitive and 60% specific.
In the workup of a potential spinal infection, which lab is the most sensitive and specific?
ESR
What kind of imaging is the TOC for spinal infection?
MRI w/ and w/o contract
___% of compression fractures will be atraumatic
30%
A 70 y/o F on long-term corticosteroid therapy comes in with back pain. She has midline TTP directly over T7. Her T-spine XR is negative for fx. What might you consider next in your workup to confirm or r/o a compression fx?
CT w/o
A kyphoplasty is indicated in someone with a compression fx with loss of ___% of vertebral high?
>50%
T/F: Whether a pt gets a kyphoplasty today or in 3 weeks, the data show no significant difference in outcomes.
False. Sooner is better.
If a pt meets 4/5 of the following criteria, this has an 85% sensitivity for ankylosing spondylitis:
- ____________________
- ____________________
- ____________________
- ____________________
- ____________________
- Morning stiffness (lol)
- Improvement with exercise
- Onset of pain at age <40
- Slow pain progression
- Pain >3 months
Ankylosing spondylitis would most likely show reduced (flexion or extension).
Reduced flexion
_______ gene is positive in 95% of cases of ankylosing spondylitis
HLA-B27
Pelvic XR in an ankylosing spondylitis pt will show….
Bilateral and symmetric sacroiliitis
“Bamboo sign” on L-spine XR should make you think of…..
Ankylosing spondylitis, although it only shows up in 10% of pts with AS.
95% of pts with a clinically important disc herniation have __________. Only ___% of them will need surgery.
Sciatica
2%
With an acute, frank disc herniation, _____ pain often overshadows back pain.
Leg
Positive SLR is ___% sensitive and ___% specific.
80% sensitive, 40% specific
Crossed SLR has ___% sensitivity and ___% specificity.
25% sensitivity, 90-97% specificity
*Jaynstein had conflicting info on her slides (typo?), but I confirmed my numbers with Professor Google.
T/F: During a SLR test, the lower the degree at pain onset, the more specific the test is and the larger the disc protrusion
True
The PEx findings of ____________________ and ____________________ together are present in 90% of pts who have surgical disc hernations
- Impaired ankle reflex
- Weak dorsiflexion
SLR is most sensitive for a herniation at which spinal level?
L5/S1
What percentage of symptomatic disc herniations undergo surgery?
2%
How can you differentiate neurogenic claudication from PVD?
Check pulses
Pain increased with spine extension should make you think of…..
Spinal stenosis
Pain not provoked by bike riding should make you think of….
Spinal stenosis
Back pain slowly progressing to constant pain with leg “stiffness” or pain should make you think of….
Spinal stenosis
Imaging for dx spinal stenosis?
- L-spine XR: degenerative changes
- MRI or CT L-spine w/o will dx
Massive midline disc herniation leading to spinal cord compression = _____________________
Cauda equina. EMERGENCY!
What are some really common sx associated with cauda equina?
- Urinary retention (90%)
- Loss of bowel/bladder sensitive but late finding!
- Saddle anesthesia (75%)
- Decreased rectal tone (60-80%)
- Sciatica and +SLR common
Workup for cauda equina includes:
- Emergenct MRI
- Emergent neurosurg consult
When might you consider an MRI in a pt with non-specific back pain?
In absence of severe/progressive neurologic sx with no improvement after >6 wks, consider MRI.
If you are concerned for infection as the cause of someone’s LBP, which lab will be most helpful?
ESR
T/F: bed rest for weeks and weeks on end is amazing for LBP, according to EBM.
GTFO
1st line pharmacologic therapy for LBP?
NSAIDs or APAP
- Neither appears superior, and combo of both has not demonstrated improved outcomes.
2nd line pharmacologic therapy for LBP?
- Muscle relaxers
- Greatest benefit in 1-2 wks, may last up to 4 wks
- If no sig improvement at 2-4 wks D/C
- Antidepressants
What are your tx goals with LBP?
- Back to baseline activity in 4 wks
- Walk 20 mins 3-4x per wk
- Re-eval in 4 wks (sooner if uncontrolled pain or progressive sx)
- ER precautions
How much wood would a wood chuck chuck if a wood chuck could chuck wood?
A wood chuck would chuck all the wood if a wood chuck could chuck wood.
