Jaynstein - Lower Back Pain Flashcards by Alice Richards

what diagnosis should you use for the 85% of patients who have lbp that can not be attributed to a specific dz

nonspecific lbp

do not give specific dx until it is absolutely proven

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7 rare conditions that must be ruled out with lbp

ankylosing spondylitis
compression fx
cancer
cauda equina
symptomatic herniated disc
spinal infxn
spinal stenosis

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2 red flag conditions for lbp that providers mc get sued over

cauda equina
spinal infxn

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lbp peaks at __ ages

55-64

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mc cause of activity limitation in persons < 45 yo

lbp

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2 primary goals for lbp in primary care setting

prevention of disability
identify red flags

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definitions of lbp from acute to chronic

acute: < 4 weeks
subacute: 4-12 weeks
chronic: > 12 weeks

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7 rf for lbp

psychological
congenital
smoking
occupation
prior episode
physical unfitness
increasing age

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strongest rf for developing lbp

psychosocial factors

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8 red flags w. lbp

trauma
unexplained wt loss
neuro sx
age > 50
fever
IVDU
steroids
hx cancer

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lbp w. recent chiropractor manipulation is concerning for

vertebral dissection

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when is lbp considered metastatic dz until proven otherwise

pt w. hx of ca

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3 cancers that mc metastasize to spine/bone

breast
lung
prostate

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4 characteristics of lbp related to ca

unexplained wt loss
pain > 1 mo
failure to improve w. conservative tx
night time pain

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work up for suspected lbp related to ca (2)

CBC
plain films

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4 mc causes of spinal infxn

urinary infxn
indwelling catheter
skin infxn
IVDU

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t/f: fever is a sensitive indicator of spinal infxn

f!!

only 40% sensitive overall

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PE finding that is relatively sensitive/specific for lbp related to spinal infxn

spinal tenderness -> specific focal pain

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lab work up for spinal infxn (5)

UA
CBC
blood cultures
lactate
ESR

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most sensitive lab to detect spinal infxn

ESR!

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imaging of choice if you suspect spinal infxn and ESR is positive

MRI w. and w.o contrast

if negative -> high rule out sensitivity

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compression fx mc occur in what pt pop

osteoporosis -> caucasian > 70 yo

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what pt population w. lbp is a compression fx until proven otherwise

pt’s on longterm steroids

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order of imaging for compression fx

plain films -> first line
if negative, CT w.o contrast

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2 surgical procedures used for compression fx

kyphoplasty vertebroplasty

5 screening factors for ankylosing spondylitis

morning stiffness improvement w. exercise onset of pain at age < 40 yo slow pain progression pain > 3 mo

t/f: screening for ankylosing spondylitis is specific

cornerstone characteristic of lbp related to ankylosing spondylitis

reduced flexion

work up for ankylosing spondylitis (3)

HLA B27 pelvic xray lumbar spine xray

pelvic xray finding of ankylosing spondylitis

bilateral, symmetric sacroilitis

lumbar spine xray finding of ankylosing spondylitis

bony sclerosis bamboo spine

95% of pt's w. symptomatic disc herniation have __

sciatica

with an acute herniation, __ often overshadows back pain

leg pain

what age does does lumbar disc herniation peak

30-55 yo

2 bedside screening PE tools for disc herniation

SLR crossed SLR

w. SLR, pt has increased pain between __ angles

30-60 after 60 degrees, the pain should remain constant and is negligible

what is the crossed SLR

raise straight leg 30-60 degrees -> positive if elicits pain on opposite side

what increases specificity of SLR, and also indicates larger disc protrusion

lower degree of pain onset

SLR is most sensitive for disc herniation at which vertebrae

L5/S1

most sensitive AND specific PE findings for disc herniation

positive SLR AND positive crossed SLR

4 signs of neuro compromise and need for surgical intervention w. lumbar disc herniation

ankle dorsiflexion weakness great toe extensor weakness decreased pinprick sensation impaired ankle reflex

what 2 PE findings are found in 90% of pt's who need surgical intervention for lumbar disc herniation

impaired ankle reflex weak ankle dorsiflexion

imaging of choice for lumbar disc herniation

MRI

who should get MRI for lumbar disc herniation (2)

significant PE findings PLUS pain or sx > 6 mo

pain in the legs, and sometimes neuro deficits, that occurs after standing or walking

neurogenic claudication

what does neurogenic claudication make you think of

spinal stenosis

neurogenic claudication is always __lateral

how do you differentiate spinal stenosis/neurogenic claudication from PVD

check pulses

what do you think when you see: lbp that slowly progresses to constant pain w. leg stiffness or pain

spinal stenosis

what do you think when you see a pt w. lb who tells you that the pain is NOT aggravated by bike riding

spinal stenosis

spinal stenosis pain is aggravated by __

spine extension usually it's flexion w. other causes

order of imaging for spinal stenosis

1. lumbar xray -> high r.o value 2. if positive -> MRI or CT w.o contrast

gs diagnostic imaging for spinal stenosis

MRI w.o contrast

xray finding of spinal stenosis

degenerative changes

history finding of pt w. cauda equina

herniated disc

what sx is seen in 90% of pt's w. early cauda equina

urinary retention (not incontinence)

2 late findings of cauda equina

bowel incontinence urinary incontinence

what type of anesthesia is seen in 75% of pt's w. cauda equina

perianal (saddle)

decreased __ tone is seen in 60-80% of pt's w. cauda equina

rectal

3 PE findings of cauda equina

sciatica positive SLR sensory/motor deficits

management of cauda equina

MRI emergent neuro consult

mainstay of diagnosis for all lbp conditions

good h&p

2 things that should NOT be considered first line for any lbp conditions

labs imaging

5 indications to obtain spinal imaging for lbp

1. high risk for compression fx 2. suspected infxn, cauda equina, progressive/severe neuro deficits 3. risk factors for ca (unless age is only rf) 4. suspected radiculopathy or spinal stenosis 5. no improvement after > 6 weeks

what imaging should you order if a pt has lbp with no improvement > 6 mo

MRI

3 labs that are useful for eval of lbp (in order of usefulness)

1. ESR 2. CBC 3. lactate/cultures

work up including __ (2) is sufficient in the majority of lbp patients w. red flags

xray ESR

t/f: patient's pain level correlates w. the severity of injury

what is pain level useful for in eval of lbp

to guide activity modification

4 first line tx for lbp

PT massage acupuncture manipulation

__ has less favorable outcomes for lbp

bed rest

first line pharm for lbp (2)

NSAIDs APAP

2nd line pharm for lbp (2)

gabapentin antidepressants

topical meds for lbp (2)

voltaren gel lidocaine patches

procedure for lbp

trigger point injxns

tx for nerve pain (2)

gabapentin lyrica

what can be used to break the pain cycle for lbp

vicodin but a very small amt (2-3 days)

pt with lbp should aim to get back to baseline activity w.in __ weeks

walking recs for lbp

20 min 3-4 x/week

f/u for lbp

4 weeks sooner if progressive sx