Week 9: Falls, Rheum, and MSK Flashcards
What red flags are important to assess in a patient with back pain?
Neurologic
Infection
Fracture
Tumor
Inflammation
(NIFTI)
When assessing for neurologic red flags in back pain, what are you looking for? What do you do if a red flag is identified?
-diffuse motor/ sensory loss
-progressive neurological deficits (progressive motor weakness or significant motor deficits not localized to single unilateral nerve root)
-cauda equina syndrome (saddles anesthesia, bladder or bowel incontinence)
-emergency MRI indicated with specialist consultation
When assessing for infectious red flags in back pain, what are you looking for? What do you do if a red flag is identified?
-fever
-IVDU
-immunosuppressed
-XR, MRI indicated
When assessing for red flags for fracture in back pain, what are you looking for? What do you do if a red flag is identified?
-hx trauma
-osteoporosis risk/ fragility fracture
-XR (and possibly CT) indicated
What red flags may suggest tumour in back pain? What do you do if a red flag is identified?
-hx of cancer
-unexplained weight loss
-significant unexpected night pain
-severe fatigue
-XR and MRI indicated
What red flags in your assessment of back pain suggest inflammation? What would you do if these were identified?
-chronic low back pain >3 months
-age of onset <45
-morning stiffness >30 minutes
-pain improves with exercise
-disproportionate night pain
-rheumatology consultation recommended (core back tool) (I would also suggest imaging/ labs to start inflammatory arthritis work up)
What are yellow flags in back pain?
psychosocial risk factors for developing chronic pain. They include
-belief that back pain is harmful or potentially severely disabling
-fear and avoidance of activity or movement
-tendency to low mood and withdrawal from social interaction
-expectation of passive treatment rather than a belief that active participation will help
What to do if yellow flags for back pain are identified?
education and reassurance to reduce risk of chronicity. Consider PHQ-4.
Sally, age 65, has constant, back dominant pain that is much worse when she bends over to tie her shoes. What pattern/ etiology of low back pain does this suggest?
Disc pain
Carlo, age 63, has been experiencing low back pain and pretty severe pain down his left upper leg that comes and goes. His pain is worse when he walks his dog or stands. His pain resolves with sitting or when he flexes forward. What pattern/ etiology of low back pain does this suggest?
Spinal stenosis
(neurogenic claudication)
Lily, age 70, has been experiencing intermittent low back pain that seems to be worse with reaching over head, or certain yoga poses, like bending backwards. What kind of patter/ etiology of back pain does this suggest?
Facet joint pain
Elvis, age 80, has been experiencing bad right leg pain that seems to start in his lower back. He states that it is always there and he just cant seem to get rid of it. Everything hurts. What pattern/ etiology of back pain do his symptoms suggest?
Compressed nerve pain
Sam has been experiencing low back pain associated with some numbness to their inner thighs. What pattern/ etiology of back pain do their symptoms suggest?
Red flag- ?cauda equina
Ask about urinary retention, overflow incontinence, fecal incontinence
May require ED- urgent MRI
82 year old Ellen has been experiencing constant mid/ low back pain for the last week that is just not going away. She denies any falls or acute injuries to her back. Phx- history of polymyalgia rheumatica, which her symptoms have been improving after being on prednisone for 6 months. Life long smoker. Ht 5’2 (last visit- 5’3). What pattern/ etiology of back pain do her symptoms suggest?
red flag- r/o fracture given osteoporosis risk (chronic glucocorticoid use, smoking hx, height loss)- send for XR
You are performing a physical exam on a patient with back pain. You do a straight leg raise test. Describe how this test is done and why you did it.
-patient supine, examining raises symptomatic leg at hip with knee extended and foot dorsiflexed.
-this increases dural tension in lower lumbar/ upper sacral spine
-if pain worsens or occurs during test, it suggess a radiculopathy (i.e., herniated disc with nerve root compression)
What are the minimum components of a back exam, per the core back tool?
-movement testing in flexion
-movement testing in extension
-patellar reflex (L3-L4)
-great toe extension power (L5)
-great toe flexion power (S1)
-plantar response (upper motor test)
-passive striaght leg raise
-saddle sensation testing (s2-3-4)
What parts of the spine does OA commonly affect?
c spine, l spine
facet joints in spine
Bonus question that might be helpful for reading XR in future-
What XR findings suggest OA?
-joint space narrowing
-subchondral sclerosis
-osteophytes
-subchondral cysts
What is spondylosis?
Arthritis of spine (disc space narrowing, arthritic changes of facet joint)
What is spondylolisthesis?
displacement of vertebral body relative to the one below (usually anterior displacement)
What is spinal stenosis?
Local, segmental, or generalized narrowing of the vertebral canal by bone or soft issue elements
Usually caused by bony hypertrophic changes in facet joints and thickening of ligamentum flavum
What is a radiculopathy?
impairment of nerve root, usually causing radiating pain, numbness, tinging, muscle weakness corresponding to specific nerve root
What actually is cauda equina syndrome?
Loss of bowel and bladder control and numbness in the groin and saddle area of the perineum, associated with weakness of the lower extremities.
Can be caused by abnormal pressure on the bottom-most portion of the spinal canal and spinal nerve roots, related to either bony stenosis or a large herniated disc.
What is kyphosis?
outward curve (convexity) of thoracic spine- can caused rounded/ hunched shoulders