HYHO SPE 3-3 Low Back Pain-Kidney Stones (8 test Qs from this, 3 are OMM)

Question 1

Features with low back pain (LBP) suggesting underlying systemic disease

Answer 1

1. Hx of cancer
2. Age >50
3. Unexplained weight loss
4. Duration of pain > 1month
5. Nighttime pain
6. Unresponsiveness to previous therapies

Question 2

What are the three types of LBP and their durations

Answer 2

1. Acute: lasts < 4 wks
2. Subacute: lasts 4 - 12 wks
3. Chronic: lasts > 12 wks

Question 3

List the 5 more serious causes of LBP, briefly describe each

Answer 3

1. SPINAL CORD or CAUDA EQUINA COMPRESSION: most commonly d/t disc herniation; pain is 1st symptom of cord compression but motor (weakness) and sensory findings present too; bowel/bladder dysfunction present later
2. METASTATIC CANCER: bone most common site of metastasis; hx of cancer (exclusing nonmelanoma skin cancer) is strongest risk factor for back pain from bone metastasis
3. SPINAL EPIDURAL ASCESS: rare; nonspecific s/s initially (i.e. fever and malaise), overtime localized back pain followed by radicular pain, and finally neurologic deficits
4. VERTEBRAL OSTEOMYELITIS: back pain which gradually increases over weeks to months; +/- fever
5. ETIOLOGIES OUTSIDE THE SPINE: pancreatitis, nephrolithiasis (*blood in urine is key for this), pyelonephritis, abdominal aortic aneurysm, herpes zoster

Question 4

Lumbar nerve root is comprised of what levels?

Answer 4

L4,5, & S1

Question 5

How do you test for L4 spinal nerve and what motor weakness results from damage?

Answer 5

Test: squat and rise

Motor weakness: extension of quadriceps

Question 6

How do you test for L5 spinal nerve and what motor weakness results from damage?

Answer 6

Test: heel walking

Motor weakness: dorsiflexion of great toe and foot

Question 7

How do you test S1 spinal nerve and what motor weakness results from damage?

Answer 7

Test: Walking on toes

Motor weakness: plantar flexion of great toe and foot

Question 8

Viscerosomatic (sympathetic) levels for:

Head/Neck (includes upper esophagus)
Heart
Lungs

Answer 8

Head/Neck: T1 - T5
Heart: T1 - T6
Lungs: T1 - T7

Question 9

Viscerosomatic (sympathetic) levels for:

Upper GI (includes lower esophagus)

Answer 9

T5 - T10

Question 10

Viscerosomatic (sympathetic) levels for:

Small intestine/ Ascending colon

Answer 10

T9 - T11

Question 11

Viscerosomatic (sympathetic) levels for:

Ascending and Transverse colon

Answer 11

T10 - L2

Question 12

Viscerosomatic (sympathetic) levels for:

Descending and Sigmoid colon/ Rectum

Answer 12

T12 - L2

Question 13

Viscerosomatic (sympathetic) levels for:

Adrenal

Answer 13

T5 - T10

Question 14

Viscerosomatic (sympathetic) levels for:

Genitourinary tract (includes bladder)

Answer 14

T10 - L2

Question 15

Viscerosomatic (sympathetic) levels for:

Ureter - Upper/Lower

Answer 15

T10 - T11/ T12 - L2

Question 16

Parasympathetic viscerosomatics for heart, lungs, esophagus, upper GI, small intestine, kidneys, ascending and transverse colon, upper ureter

Answer 16

Vagus n. (OA and AA)

Question 17

Parasympathetic viscerosomatics for colon, rectum, reporductive organs, bladder, pelvis, lower ureter

Answer 17

S2 - S4 (sacrum)

Question 18

When should an MRI be done for a complaint of back pain?

Answer 18

For any patients with symptoms of spinal cord or cauda equina compression or progressive and/or severe neurologic deficits

Question 19

If a patient has radiculopathy attributable to a single nerve root level or with stable symptoms due to spinal stenosis, should imaging be done immediately?

Answer 19

NO.

Immediate imaging only needed if there is a risk of metastatic cancer or moderate to high risk of infection - in which cause do an immediate MRI

Question 20

What are some “red flag” symptoms that may identify pts at risk for a more dangerous cause of back pain?

Answer 20

1. History of cancer

Red flags associated with vertebral fracture:

1. Older age
2. Prolonged use of corticosteroids
3. Severe trauma
4. Presence of contusion or abrasion

Question 21

What diagnostic imaging should be done when suspecting nephrolithiasis?

Answer 21

CT of abdomen and pelvis withOUT contrast using low-radiation-dose protocols

If CT not available –> ultrasound of kidneys and bladder in combo with abdominopelvic radiography

Question 22

The following pivotal points/clinical clues lead to what diagnosis/cause of back pain:

urinary retention, saddle anesthesia, bilateral leg weakness, bilateral sciatica

Answer 22

Cauda equina syndrome

Question 23

The following pivotal points/clinical clues lead to what diagnosis/cause of back pain:

fever, recent skin or urinary tract infection, immunosuppression, injection drug use

Answer 23

Infection

Question 24

The following pivotal points/clinical clues lead to what diagnosis/cause of back pain:

cancer history (especially active cancer), unexplained weight loss, age over 50, duration > 1 month

Answer 24

Malignancy

Question 25

The following pivotal points/clinical clues lead to what diagnosis/cause of back pain:

age over 70, female sex, corticosteroid use, hx of osteoporosis, trauma

Answer 25

Compression fracture

Question 26

The following pivotal points/clinical clues lead to what diagnosis/cause of back pain:

sciatica, abnormal neurologic exam

Answer 26

Lumbar radiculopathy

Question 27

Pharmacologic therapy for LBP management

Answer 27

Initially: short term (2-4 wks) NSAID; acetaminophen is acceptable alternative in pts w/contraindication to NSAIDs

For pts with pain refractory to initial tx: add NONbenzodiazepine muscle relaxant

Finally: opoids and tramadol but be very cautious; limit use to 3-7 days and only prescribe tramadol for max 2 weeks