Back Pain

Question 1

Epidemiology

Answer 1

2nd most common complaint in primary care, 66% lifetime risk in adults;60-70% of cases resolve in 6 weeks, 80-90% by 12 weeks.

Question 2

Etiologies of back pain

Answer 2

Muscular or ligament injury (70%)
Degenerative joint disease (10%)
Disk Herniation (4%)
Compression fracture (4%)
Spinal stenosis (3%)
Spondylolithesis (2%)
Malignancy (<1%)
Epidural abscess, vertebral osteomyelitis, discitis (0.1%)
Spondyloarthropathies (<1%)
Extraspinal (2%)

Question 3

Common Presenting Symptoms

Muscle or ligament injury

Answer 3

Sudden onset of pain, often w/precipitating movement, may radiate to buttock, upper thigh; feeling of something giving way.

Question 4

Common Presenting Symptoms

Degenerative joint disease

Answer 4

chronic, subacute pain often assoc w/other OA

Question 5

Common Presenting Symptoms

Disk Hernation

Answer 5

L5-S1 most common; + straight leg test; worse w/coughing, straining; sciatic pain (sharp/burning, radiating down buttock, thigh, or leg) in dermatomal distribution.

Question 6

Common Presenting Symptoms

Compression Fracture

Answer 6

Sudden onset of pain in pt w/risk factors for fracture (ie osteoporosis, steroid use, malignancy, elderly) after coughing, bending, lifting, or minor trauma; loss of height, point tenderness; may be presenting sign of osteoporosis.

Question 7

Common Presenting Symptoms

Spinal stenosis

Answer 7

Pain in lower back, buttocks (pseudoclaudication), wide gait, paresthesia’s (often bilateral), worsened by standing, walking (downhill>uphill, in contrast to claudication) and decrease by sitting/bending/leaning forward

Question 8

Common Presenting Symptoms

Spondylolisthesis

Answer 8

Forward subluxation of vertebrae causes chronic ligamentous pain worse w/activity, relieved by rest

Question 9

Common Presenting Symptoms

Malignancy

Answer 9

Gradual onset of pain w/ activity, unrelieved/worsened by supine position; may be accompanied by incontinence/urinary retention, saddle anesthesia, muscle weakness, wt loss; breast; gi; lung; lymphoma/leukemia, myeloma, and prostate most common malignancies

Question 10

Common Presenting Symptoms

Epidural abscess, vertebral osteomyelitis, discitis

Answer 10

Fever, back pain, neuro deficit in minority of pts; risk factors include instrumentation, HIV, IVDU or TB, and hematogenous seeding from a UTI, catheter, or abscess

Question 11

Common Presenting Symptoms

Spondyloarthropathies

Answer 11

Skeletal manifestations of psoriatic arthritis, IBD; AS; onset of pain insidious, improves w/motion, worse in the morning/better at night, and typically occurs in female patients 20-40 years

Question 12

Common Presenting Symptoms

Extraspinal

Answer 12

Referred pain from hip, SI joint; AAA/TAA, endometriosis, fibroids, nephrolithiasis, pancreatitis, cholecystitis, pyelonephritis, neuropathy, claudication

Question 13

L4 Sensory

Answer 13

Pain radiating to anterior thigh; sensory abnormalities anterior-lateral thigh, medial calf

Question 14

L5 Sensory

Answer 14

Pain to buttock, down lateral thigh and calf to foot; sensory abnormalities lateral calf, great toe

Question 15

S1 Sensory

Answer 15

Pain to buttock, down posterior tight/calf to lateral foot; decrease sensation plantar/lateral foot, posterior leg

Question 16

L4 Motor

Answer 16

Difficulty rising from chair, extending leg at knee, heel walk; decrease patellar reflex

Question 17

L5 Motor

Answer 17

Difficulty w/heel walk, dorsiflexion of great toe; normal reflexes

Question 18

S1 Motor

Answer 18

Difficulty w/toe walk; decrease plantarflexion of toe and foot; decrease ankle reflex

Question 19

History

Answer 19

Location, provocative/palliative factors, quality, radiation, severity, timing, hx trauma/back pain

Assoc sx: fever, bowel/bladder incontinence, neuro deficits, saddle anesthesia

Risk factors: steroid use, malignancy, infection, depression, avoidance behaviors, ergonomics

Question 20

Occupational Injury

Answer 20

Documentation of injury history, functional limitation; risk factors for chronic disabling back pain include pre-existing psychological problems/chronic pain, job dissatisfaction

Question 21

Exam

Answer 21

Flexibility of spine; palpation of spine; toe/heel walk, rising from chair, neuro exam (strength, sensation, reflexes); pedal pulses; observation of walking; spontaneous activity (getting on/off table, getting dressed) helpful; exam of hip joint

Question 22

Straight-leg test

Answer 22

Somewhat useful for detecting herniated discs (91% sensitive, 26% specific); with patient supine and leg extended, examiner lifts leg at heel -> considered + if sciatica reproduced between 30-70 degrees.

Question 23

Crossed straight-leg raise

Answer 23

elevation of opposite leg reproduces sx (increase specific)

Question 24

Workup

Answer 24

Hx/PE suggestive in most cases; imaging in absence of red flags does not improve clinical outcomes; abnl findings common in asx pts

Question 25

Labs

Answer 25

Guided by clinical scenario; consider ESR/CTP, CBC, BCx, A0, HLA-B27 (inpts w/idiopathic back pain >3 months and <45 years w/possible spondyloarthritis); for pts on chronic opiods, random drug testing to assess for presence of opiods (prevent diversion) and detect substance use d/o

Question 26

Radiographs

Answer 26

Useful in diagnosing compression fractures, ankylosing spondylitis

Question 27

MRI

Answer 27

Cauda equina syndrome, epidural abscess, malignancy, approx. 2/3rds of healthy adults without back pain have abnl findings on spine MRI and sc may not relate to imaging findings

Question 28

EMG and NCS

Answer 28

Useful in pts w/subacute radiculopathy and an unrevealing MRI

Question 29

Red Flags to Prompt Imaging

Answer 29

``` Unexplained fevers or wt loss Immunosuppression Age>70 y Osteoporosis Duration >6 wks Indwelling catheter, recent UTI or cellulitis Bowel/bladder incontinence Trauma/heavy lifting & age >50 y Hx malignancy of IVDU Prolonged steroid use Focal neuro deficit New back pain in pt >50 y Pain at night Urinary retention ```

Question 30

Acute/Subacute timeframe

Answer 30

<12 wks

Question 31

Acute/Subacute Urgent surgical eval

Answer 31

Indicated for cauda equina, motor weakness, cord compression

Question 32

Acute/Subacute Medications

Answer 32

APAP+/- NSAIDs: 1st-line, scheduled for short course Topicals: lidocaine, capsaicin Muscle Relaxants: cyclobenzaprine, baclofen, tizanaidine, methocarbamol, may be combined w/NSAIDs for short course; caution re: sedation, drug interactions; avoid cyclobenzaprine in pts w/arrhythmia, CHF, hyperthyroid: low-dose diazepam may also be used (2nd line 2/2 abuse potential) Opiods: Should be used sparingly and only for a short course if needed Bisphosphonates: Pts w/ osteoporotic compression fractures and pain unrelieved by PO meds

Question 33

Acute/Subacute nonpharmacologic

Answer 33

Physical activity as tolerated: pain relief/function improved in pts advised to stay active compared to bed rest Reassurance: 90% of pts w/acute, nonspecific back pain improve in <2 weeks w/o intervention CAM: physical therapy, yoga (chronic low back pain), acupuncture, chiropractic, aquatherapy, massage tx; heat; cold compresses (acute back pain) Self-care: education books (eg the back book); back braces or abdominal binders Lifestyle modification: Good lifting techniques (bend knees, not back): lay flat w/ pillow under knees to straighten spine; firm/tempurpedic mattress; workplace ergonomic eval; padded mats if pt must stand for long periods; evidence low quality by may be helpful

Question 34

Chronic timeframe

Answer 34

>12 weeks

Question 35

Chronic Epidural steroid injection

Answer 35

Consider for chronic radicular pain from disk herniation; Cochrane review found "insufficient evidence to support use in subacute and chronic low back pain...it cannot be r/o that specific subgroups of pts may respond" Contaminated steroids assoc w/2012 fungal meningitis outbreak

Question 36

Chronic Medications

Answer 36

SNRIs, TCAs

Question 37

Chronic Behavioral modifications

Answer 37

Wt loss, cognitive behavioral RX, smoking cessation

Question 38

Chronic Herniated discs and spinal stenosis

Answer 38

Surgical correction for herniated discs (discectomy or microdiscectomy) or sx spinal stenosis (laminectomy or intraspinous spacer implantation) assoc w/short-term benefits compared to conservative mgmt. that diminish over time; pts treated w/nonoperative mgmt. for herniated discs improv substantially over 2 y

Question 39

Chronic Vertebral Fusion

Answer 39

Degenerative spondylolisthesis w/laminectomy; consider for pts w/>1y disabling nonspecific back pain refractory to behavioral modification/intensive interdisciplinary rehabilitation

Question 40

Chronic Osteoporotic Compression Fractures

Answer 40

Vertebroplasty provided no benefit compared to sham procedures

Question 41

Chronic Other (multidisciplinary specialist consultation recommended)

Answer 41

Best evidence for multidisciplinary rehab/chronic pain clinic and CBT; other options include ablation, intrathecal analgesic pumps; chronic pain clinic referral; pts who fail back surgery for disc herniation may benefit from spinal cord stimulation; facet joint injections