Back Pain

BACK PAIN PATIENT CARE 1. General Information  90% of acute lower back pain will resolve in one month w/out treatment  A specific pathoanatomic diagnosis is established in less than 20% of patients  Good Review in Noble on MD Consult MEDICAL KNOWLEDGE 1. History  Onset, radiation, location, modifying factors, etc.  Sensory or motor Sx’s  Trauma Hx: fracture or disk herniation. Flexion injury leads to disk herniation  Morning stiffness relieved by exercise points to rheumatic disease o Ask about urethritis, conjuctivits, rash, bowel habits, tick bites  Localized bone pain in elderly may point to met or MM  Sitting makes worse = disk, sitting makes better = spinal stenosis  Lying with knees flexed relieves pain = disk disease 2. Red Flag Symtpoms  Cancer: Hx, weight loss, persistence of pain, pain at night, elderly  Infection: fever, urinary Sx’s, immunocompromised  Cauda Equina: urinary and anal incontinence, saddle anesthesia, bilateral lower extremity numbness and weakness  Significant disk disease: muscle weakness and foot drop  Compression fracture: elderly, steroids, osteoporosis, MVA or fall  AAA: check for abdominal pulsing mass 3. Physical Exam  Observe: chest expansion (reduced with AS), iliac crest level, shoulder level  Check ROM and look for acute scoliosis or lordosis secondary to muscle spasm  Tendernous over spinous processes: infection or malignancy or fracture. Step off at L5 suggests spondylolisthesis  Most important maneuver is the strait leg raise test to differentiate strain from radiculopathy: o Pain in radicular distribution with < 60 degrees elevation o Ipsi = 80% sensitive but 40% specific o Contra = 25% sensitive but 90% specific  Can also extend hip to check for L3/L4 herniation

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Neuro exam of the foot including motor, sensory (light touch and proprioception) and reflexes o Diminished Achilles indicates L5/S1 herniation o Walk on toes checks plantar flexion and S1 o Walk on heels checks dorsifelxion and L5 Remember dermatomes: S1 = little toe, L5 = big toe. Disk herniation gets the lower root in the disk (i.e. L5/S1 gets S1)

4. Differential Diagnosis  Musculoskeletal: ligamentous strain, muscle strain/spasm  Disk Herniation  Compression fracture: From osteoporosis, more common in thoracic spine but can have lumbar  Spinal Stenosis: bony encroachment from osteoarthritis on congenitally narrow cannal  Spondylolishtesis: slippage of one vertebrae over another  Infection: Abscess, Potts, Pyelo  Neoplasia: spinal mets, MM  Rheum: Ankylosing spondylitis, Reiter’s  Zoster 5. Evaluation  If no evidence of CE, Met, Fracture, Infection or bad neuro deficit, conservative management for 6 weeks  If radicular and no improvement, consider MRI in 6 weeks  Remember MRI false positives increase with age as there is increasing asymptomatic disk herniation  Only get MRI if it will change your management  Red Flag Labs: LS X-ray, MRI, CBC, ESR, U/A 6. Conservative Management  Data shows quicker recovery with returning to normal activities. Don’t do things that exacerbate the pain  Heat and Ice for muscle spasm  No evidence for corsets or traction  Consdier PT if not better in 2-4 weeks  Body Mechanics o Squat, don’t bend, keep a base of support o Keep equipment close to center of body o Keep back in neutral position  Add Pharm as needed (see below) 7. Pharmacologic Management

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NSAIDs are very effective in reducing pain: choose based on cost and SEs. Narcotics should be used sparingly for < 7d only as needed given potential for abuse and self-limiting course of low back pain Muslce relaxants (cyclobenzaprine, carisoprodol) should also be used sparingly for < 7d o Watch for sedation CS can be substiutied for NSAIDs but no evidence that they are better

8. Surgery  Emergent surgery necessary for some conditions.  Last resort for common low back pain  Diskectomy has good short term outcomes for disk disease, however long term outcomes are similar with conservative therapy  In addition there is a risk of serious complications like: dural tears, diskitis, nerve root damage and spinal instability  May have a long recovery