Lumbar pain and red flags Flashcards
Hx
72 yr old F 60 pack year smoking hx, sudden onset non-severe [3-4/10] thoracolumbar pain one wk ago, FHx f osteoporosis, hx of osteopenia on DEXA, on calcium and it D, some pain at night, no falls, cancer hx
feel
tenderness over thoracolumbar spine centrally
look
thoracic kyphosis
BMI low/18 in this case
active movement
painful ROM of thoracic and lumbar spine
passive and resisted movements
not expected
other tests
full lower limb near exam
hip exam bilaterally
DRE not necessary as no cauda equine symptoms, if male patient do prostate exam
DDx
vertebral compression fracture
primary or secondary tumour of spine
facet joint degeneration
non-specific low back pain
why is vertebral compression fracture [caused by osteoporosis] likely?
osteopenia
low BMI
thoracic kyphosis
tenderness and pain on active ROM thoracolumbar spine
why is primary or secondary tumour of spine unlikely?
rule out with bloods [ESR, CRP, bone profile, SPEP, Bence Jones protein] and X-rays of thoracic and lumbar spines because of smoking hx
why is facet joint degeneration unlikely?
arthritic changes possible but onset of pain would be more gradual
why is non-specific low back pain unlikely?
hx points to osteoporotic fracture
investigations
bloods xray thoracic and lumbar spine and SI joint xray chest DEXA scan MRI spine
blood tests
ESR CRP FBC PSA PTH Vit D SPEP renal profile liver profile bone profile
xray thoracic and lumbar spine and SI joint
check for osteoporotic fracture collapse of vertebral bodies, wedge fracture, vertebral mets
xray chest
if neoplasia likely
