Low Back Pain DSA Flashcards
Acute back pain
back pain lasting up to 6 weeks
Sub-acute back pain
back pain lasting 7-12 weeks
chronic back pain
back pain lasting >12 weeks
red flags for back pain
major trauma age>50 persistent fever history of cancer saddle anesthesia history of osteoporosis progressive neurologic systems bowel/bladder dysfunction history of corticosteroid use decreased anal sphincter tone unrelenting night pain major muscle weakness rheumatoid arthritis, Down's syndrome, Marfan's, Ehler-Danlos syndrome
Objective physical exam red flags
muscle atrophy
increased muscle tone (cerebral palsy)
decreased deep tendon (muscle stretch)
signs of inflammation (red, hot, swollen)
DDx for low back pain
mechanical: with(out) radiation below the knee
viscerogenic: pain from organs
vasculogenic: pain from vascular structures
infection
metablic
tumor: primary/secondary
rheumatologic
congenital
psychological
mechanical low back pain without radiation below the knee causes
SD (TART), spinal arthritis, DDD, facet arthritis, fracture, spondylolysis, spondylolisthesis, scoliosis
mechanical low back pain without radiation below the knee caused by somatic dysfunction
TART
may be chronic or acute
resolves with OMT
typically no further work up
mechanical low back pain without radiation below the knee spinal arthritis
typically chronic localized to low back and buttocks better with lying down and change of position worse with prolonged standing or sitting Work up: AP and lateral XR MRI
mechanical low back pain without radiation below the knee DDD
localized to low back and buttocks better with lying down and change of position worse with prolonged standing or sitting typically chronic Work up: AP and lateral XR and MRI
mechanical low back pain without radiation below the knee facet arthritis
localized to low back and buttocks better with lying down and change of position worse with spinal extension typically chronic Work up: AP and lateral plain films, MRI
mechanical low back pain without radiation below the knee fracture
compression fracture: history of trauma or osteoporosis
usually acute
work up: AP and lateral XR
mechanical low back pain without radiation below the knee spondylolysis
fracture of the pars interarticularis
new-onset LBP in athletically active adolescent or history of trauma
work up: AP, lateral and oblique film (scottie dog), CT
mechanical low back pain without radiation below the knee spondylolisthesis
leg pain numbness or weakness, stiff back, changes in posture or gait
grades I & II stable, grades III-V surgery
step off when palpating lumbar spine
usually chronic
work up AP and lateral XR
mechanical low back pain without radiation below the knee scoliosis
typically chronic
rib hump
Work up AP and lateral
mechanical low back pain with radiation below the knee DDx
radiculopathy
spinal stenosis
cauda equina syndrome
viscerogenic LBP DDx
kidney, GI, pancreatitis, reproductive organs
viscerogenic LBP from nephrolithiasis “kidney stones”
LBP and abdominal pain intermittent (renal colic) hematuria acute, may become chronic Work up: US, CT, UA
viscerogenic LBP from pyelonephritis
kidney infection low back and abdominal pain fever pyuria (pus in urine) typically acute, may become chronic unilateral Work up: UA, CBC, US
viscerogenic LBP from IBD: crohn’s disease and UC
abdominal pain, tenderness, and distension
bloody diarrhea
typically chronic with acute flares
Work up: abd XR, US, CT, CBC, amylase/lipase
viscerogenic LBP from diverticulitis
abd pain (especially LLQ) , tenderness, possibly fever
typically acute flares
work up: XR, CT, CBC
viscerogenic LBP from pancreatitis
back pain with abdominal pain, tenderness, and distension, nausea and vomiting
typically acute but can progress to chronic
work up: abd XR, US, CT, CBC, amylase/lipase
viscerogenic LBP from endometriosis
pelvic pain
typically chronic
work up: US, laproscopic diagnosis
viscerogenic LBP from menstrual
intermittent, cramping pelvic pain, may have nausea/vomiting/diarrhea
cyclic pain
work up: based on clinical findings
viscerogenic LBP from prostatitis
painful, frequent, urgent urination; pain with ejaculation; difficulty sitting
typically actue but may become chronic
work up: UA (possibly after prostate massage), possible US or CT
vasculogenic LBP DDx
aortic aneurysm
ischemic spinal claudation
vasculogenic LBP from aortic aneurysm
“ripping” or “tearing” abdominal pain
pulsatile abdominal mass
work up: US, CT, CTA
vasculogenic LBP from ischemic spinal claudication
ischemia - restriction of blood supply to tissues
claudication - pain caused by too little blood flow
myelopathy - any neurological deficit related to the spinal cord
acute myelopathy
work up: CTA, MRI
infection LBP DDx
discitis
herpes zoster
osteomyelitis
infection LBP from discitis
recent skin infection, UTI, or IVDA; consider in immunocompromised individuals pain at rest or at night localized pain typically acute work up: CBC, blood cultures, MRI
infection LBP from herpes zoster
pain proceeds rash
typically acute, pain may become chronic
work up: none (viral cultures available but rarely done)
infection LBP from osteomyelitis
recent skin infection, UTI, IVDA; consider immunocompromised individuals pain at rest or at night, fever localized pain typically acute work up: CBC, blood cultures, MRI
metabolic LBP DDx
osteoporosis, Paget disease
metabolic LBP from osteoporosis
chronic pain may be acute with compression fracture
work up: DEXA scan
compression fracture work up: XR
metabolic LBP from Paget disease
bone cells don’t function properly, resulting in deformed, enlarged, and fragile bones
dull, persistent, worse at night
neurologic symptoms like tingling, numbness, difficulty walking, wor bowel and bladder problems
typically chronic, acute with fracture
work up: XR, bone scan
bone scan
nuclear medicine test which uses a very small amount of a radioactive substance injected into a vein. abnormal absorption by the body may indicate disease.
LBP from tumor - primary DDx
myeloma
sarcoma
osteoid osteoma
neural tumor: neurofibroma (chr 17), schwannoma, meningioma
LBP from primary tumor - myeloma, sarcoma, osteoid osteoma
bone tumors
pain at rest, at night, night sweats, weight loss
chronic/starts insidiously
work up: XR to start, then may need CT, MRI, blood work
LBP from primary tumor - neural neurofibroma, schwannoma, meningioma
pain at rest, at night
chronic
work up: XR to start, then may need CT, MRI, blood work
LBP from secondary (metastatic) tumors of the prostate, lung, breast, or kidney
usually multiple lesions
pain at rest, at night, night sweats, weight loss
chronic/starts insidiously
work up: XR to start, then may need CT, MRI, blood work
rheumatologic LBP DDx
seronegative spondyloarthropathy: psoriatic arthritis, ankylosing spondylitis, IBD (enteropathic arthritis), Reiter syndrome
Bechet syndrome
Fibromyalgia
Rhematoid arthritis
rheumatologic LBP from seronegative spondyloarthropathy: psoriatic arthritis, ankylosing spondylitis, IBD (enteropathic arthritis), Reither syndrome
psoriatic arthritis: pencil in cup
ankylosing spondylitis: calcification of ligaments at lumbar spine - “bamboo” spine limits flexion, extension, sidebending
enteropathic colitis: inflammation within back causing chronic LBP associated with viscera
Reiter syndrome: lateral calcification
back and joint pain
typically chronic
work up: HLA-B27, XR
rheumatologic LBP from fibromyalgia
11 of 18 tender points
many symptoms
chronic
work up: diagnosis of exclusion
rheumatologic LBP from rheumatoid arthritis
morning stiffness > 1 hour, fatigue, joint arthritis
work up: RF (rheumatoid factor), XR
Congenital LBP DDx
genetic malformations: congenital scoliosis, spinal bifida, meningocele, menigomylocele
achondroplasia
collagen disorders: Marfan’s syndrome, Ehler-Danlos syndrome
congenital LBP from genetic malformations: congenital scoliosis, spina bifida, meningocele, meningomylocele
work up: maternal US
scoliosis: failure of formation and/or segmentation
spina bifida: bifid spinous process, meningocele: protrusion of meninges, meningomyelocele: nerve tissue
congenital LBP from achondroplasia
pain usually due to spinal stenosis or increased lordosis
work up: maternal US
congenital LBP from collagen disorders (Marfan’s syndrome and Ehler Danlos syndrome)
work up: history and physical exam (maybe genetic)
psychological LBP DDx
somatoform disorder
malingering
central sensitization/chronic pain syndrome
psychological LBP somatoform disorder
group of psychological disorders in which a pt experiences physical symptoms that are inconsistent with or cannot be fully explained by any underlying general medical or neurologic condition
psychological LBP from malingering
exaggerate or feign illness in order to escape duty or work
psychological LBP from central sensitization/chronic pain syndrome
condition of the NS that is associated with the development and maintenance of chronic pain. When central sensitization occurs, the NS goes through a process called wind-up and gets regulated in a persistent state of high reactivity
