Acute Back Pain in Clinic - PowerPoint Presentation

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Acute Back Pain in Clinic

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Evaluation Algorithm

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Red Flags

Age >50 (technically, but also consider complete context of s/s)

Hx

of malignancy

Bowel/bladder dysfunction, saddle anesthesia, bilateral sciatica

Fever

IVDU

Recent endovascular procedure

Chronic corticosteroid use/osteoporosis

Trauma

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Back Pain: Can’t miss diagnoses

Cauda

Equina

Malignancy

Infection

Fracture

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DDx: Cauda

equina

syndrome

Hx

and PE

Bladder

, bowel incontinence

Urinary retention

Progressive motor, sensory loss

Motor weakness, sensory

deficit on exam

Loss anal sphincter tone

Saddle anesthesia

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DDx: Malignancy

Hx

and

PE

Cancer

metastatic to bone

-> breast, lung, thyroid, MM, kidney (RCC), prostate

“

BLT w/ Mayo, Mustard, and a Kosher Pickle

”

Unexplained

weight loss

Pain increased/unrelieved

by rest

Vertebral

tenderness

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DDx: Infection

Hx

and

PE

Severe pain + lumbar spine surgery w/in past 1 year

IVDU

Immunosuppression

Pain increased/unrelieved by rest

Fever

UTI

Soft tissue wound on back

Vertebral tenderness

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DDx: Fracture

Hx

and

PE

Significant trauma related to age

Younger adult -> fall from height, MVA

Elderly patient/with osteoporosis -> minor fall, heavy lifting

Prolonged steroid use

Age > 70

Hx

of osteoporosis

Vertebral tenderness

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Back Pain: Common diagnoses (Frequency)

Lumbar strain (80%)

Herniated disk (3-4%)

Compression fracture (3-4%)

Spinal stenosis (3%)

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Low back exam (no red flags)

If likely MSK from

hx

:

Inspection

Standing upright

Bending forward

Palpation of

Spine/center of back -> midline tenderness

paraspinal

muscles

Provocative tests

Straight leg test, straight leg variant

Tripod sign

Femoral stretch test

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Low back exam (no red flags)

If severe, prolonged pain or concern for

neuro

dysfunction from

hx

->

neuro

exam focusing on L4, L5, S1 nerve roots

Motor

exam

L4 -> flex knee, kick out with lower leg

L5 ->

dorsiflex

big toe and/or walk on heels

S1 ->

plantarflex

foot and/or walk on toes

Sensory

exam

L4 ->

anterolateral thigh

L5

->

dorsal aspect between 1

st

and 2

nd

toe

S1 -> lateral foot

Reflex

exam

L4 ->

patellar

L5 ->

na

, medial hamstring

S1 ->

achilles

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DDx

: Lumbar strain/sprain

Hx

and

PE

Most

common cause back pain,

a/w

overuse, ages 30-60

Diffuse back pain

+/- buttock pain

Worse with movement, improves with

rest

TTP of

paraspinal

muscles

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DDx: Herniated Disk (nucleus pulposus

)

Hx

Rare

after age 60

Acute onset radicular pain

Leg pain > back pain

L1-L3

 radiates to hip, anterior thigh

L4-S1  radiates to below knee

Worse with sitting

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Herniated Disk

PE

Straight-leg test:

pt

supine, knee extended, hip gradually flexed

Pain reproduced < 60

o

of hip flexion on

ipsilateral

side -> + test, more

sensitive

Pain reproduced < 60

o

of hip flexion on

contralateral

side -> + test, more

specific

Pain reproduced

>

60

o

of hip

flexion = tight hamstrings

Femoral stretch test for upper L disk herniation:

pt

prone, knee flexed, leg extended

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Herniated Disk

PE

Tripod sign -> are you unsure/is your

pt

malingering?

Pt seated -> elevate one leg -> if elicits pain in back/radiation to leg ->

pt

will naturally try to relieve pain by leaning back and supporting self with hands (=the tripod)

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DDx: Compression Fracture

Hx

Most

common in women, age > 70, with osteoporosis,

hx

of

trauma, low body weight

Acute onset

Worse

with flexion

Worse with getting up: supine

 sitting 

standing

Loss of standing height (if multiple/

hx

of compression

fxs

)

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Compression Fracture

XR of

a compression fracture: a lateral radiograph of an L2 compression fracture (A). Wedging of the vertebral body is seen

PE

Midline tenderness of vertebra

Kyphotic

deformity

Loss of lumbar lordosis

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DDx: Spinal Stenosis

Typically 2/2 degenerative changes in spine (

spondylosis

)

Age

>

60

Other RFs: previous back surgery, previous injury

Insidious onset

Worse walking and upright

Improves with rest,

sitting, spine

flexed

Leg pain > back

pain

Radiculopathy, neurogenic claudication, LE

paresthesias

Unilateral (

foraminal

stenosis) or bilateral (central or bilateral

foraminal

stenosis)

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Spinal Stenosis

MRI of

spinal stenosis: (A) demarcates the normal sagittal diameter of the spinal canal. (B) demarcates severe narrowing of the spinal canal

PE:

Uncommon to have

neuro

deficits

May have stooped posture when walking (shopping cart sign)

Straight leg test usually negative

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DDx: Spondylolisthesis -> change in position of one vertebral body compared to another

Leg pain > back pain

Worse with standing, walking

Improves with rest, spine flexed

Unilateral or bilateral

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Degenerative Spondylolisthesis -> 2/2 degenerative dz

,

spondylosis

PE

Exaggerated lordosis

Midline step-off of

spinous

process -> L shape anterior to posterior

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DDx: Spondylosis

(degenerative disk/facet joint

arthropathy

)

Worse with standing, sitting (axial loading), exacerbated by movement

Improves with recumbence, rest

Disk

pain worse with flexion, sitting

Facet pain worse with extension, standing,

walking

Pain can be referred to

paraspinal

muscles,

gluteals

, posterior thighs

radiculopathy

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DDx: Spondylosis

(degenerative disk/facet joint

arthropathy

)

Spine flexion reproduces

sxs

Spine extension relieves

sxs

Uncommon to have

neuro

deficit

Straight leg test usually (-)

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When should you image?

Typically don’t image in acute low back pain -> RCTs have shown no difference in patient outcomes

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When should you image?

If high suspicion for:

Vertebral fracture -> XR

Infection -> MRI (CT)

Cauda

equina

-> MRI (CT)

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First visit for back pain

Patient counseling

Reassurance -> most cases resolve with limited intervention in 4-6 weeks

Stay active (within pain limits) -> return to normal activities as soon as possible

Minimize twisting, bending, heavy lifting

Non-opioid analgesia

PT referral

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Treatment: Medications

PO Meds

:

NSAIDs or Acetaminophen

Muscle relaxant if more severe:

methocarbamol

, cyclobenzaprine

Can also consider gabapentin

,

anti-depressants

Topical Meds:

Diclofenac gel

Lidocaine gel

Capsaicin cream

Salon pas patches (OTC, not available in pharmacy)

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Treatment: PT

Therapeutic exercise -> core strengthening, stretching of ITB, hamstrings, hip flexors

Patient education -> spinal mechanics, lifting and moving mechanics

Back Group Class -> incorporates CBT

Other modalities -> ultrasound, electrical stimulation (no evidence)

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Treatment: Other

Weight loss

Back brace -> short term use only (<2-3 weeks

)

Ice or heat -> patient experimentation/preference (no evidence)

Epidural steroid injections -> radicular pain not responsive to conservative management after 4-6 weeks

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Avoid:

Opioids

Bed rest

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When to eConsult Ortho Spine/NSG per DHS expected practices

1. Neurologic

signs or symptoms like neurogenic claudication, radiculopathy (neurogenic pain

of arms

or legs persisting beyond 2 months without adequate improvement).

2. Imbalance or incoordination consistent with myelopathy.

3. Instability (e.g., spondylolisthesis, adjacent level disease next to old fusion) or deformity (e.g

., scoliosis

,

flatback

, kyphosis) are potentially amenable to surgery - in some cases.

4. Previously operated patients may need surgical assessment for residual stenosis, non-union of

a fusion

, or adjacent level disease. Some of these may be deemed to have "failed back

syndrome"and

no longer in need of further surgery if the surgery appears fine but the pain persists.

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MSK Mimics

Hip problems

Trochanteric bursitis

Hip arthritis

Ankylosing

Spondylitis

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Non-MSK Mimics

AAA -> male sex, age > 60, tobacco use

PUD

Pancreatitis

Pyelonephritis

Herpes zoster -> don’t forget to inspect the skin!

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References

BMJ Best Practice, “Evaluation of back pain”

https://

bestpractice.bmj.com/topics/en-us/189/diagnosis-approach

Casazza

, B. “Diagnosis and Treatment of Acute Low Back Pain.”

American Family Physician

. 85, 4 (2012): 343-350.

DHS Clinical Care Library, “Approach to Chronic Low Back Pain

Expected

Practice”

http

://

myladhs.lacounty.gov/DHSCR/dhsccl/Orthpaedics/Forms/AllItems.aspx

Stanford Medicine 25 “Approach to the Low

Back Exam”

http://

stanfordmedicine25.stanford.edu/the25/BackExam.html

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