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Acute Low Back Pain

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Emily U

on 23 January 2014

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Transcript of Acute Low Back Pain

Patient returns with 10/10 low back pain
LUMBAR XRAY: Closed compression fracture of L2 vertebral body
PLAN:
MR Lumbar Spine Requested
Diclofenac Sodium 75MG Oral Tablet, Take 1 tablet BID
KEY POINTS
* Red flag sx in LBP should prompt immediate diagnostic workup

* Eval Cauda equina syndrome ASAP by MRI! Surgical emergency

*Herniated disc can be treated conservatively for 4 weeks before imaging has any proven benefit

*Lumbar strain is common, generally resolves within a few weeks, and is treated with NSAIDS, muscle relaxants, and no more than 2 d of bed rest
Family Medicine Case Presentation
Emily Utschig
OMS III
Western University of Health Sciences


CHIEF COMPLAINT
"Mi espalda me ha dolido por un mes"
HPI
New patient: 78-year-old Spanish speaking male presents with worsening LBP (R>L) x 1 month. Pain is intermittent, 8/10 throbbing/stabbing with radiation to the R thigh and R lower leg. Symptoms are only slightly improved by rest, heat and Advil and exacerbated by prolonged sitting, standing or bending. He denies inciting event but admits to a fall 8 years ago from 20 feet with subsequent rib fractures and hemothorax. Patient denies fever, denies night sweats, denies urinary frequency, denies abdominal pain.
PAST MEDICAL HISTORY
None reported
PAST SURGICAL HISTORY
None reported
MEDS
None reported
ALLERGIES
NKDA
REVIEW OF SYSTEMS
General: No unexplained weight loss, no night sweats, no fatigue/lethargy
Cardiovascular: No chest pain, no DOE, no palpitations
GI: No n/v, no diarrhea/constipation, no abd pain
GU: No dysuria, no hematuria, no polyuria
Neurological: No headache, no memory loss, no changes in sight/smell/hearing
PHYSICAL EXAM
CONSTITUTIONAL: Well developed and well nourished
HEAD AND FACE: Head and face are normal in appearance and facial strength is normal
EARS, NOSE, MOUTH, THROAT: External inspection of the ears and nose is normal. Hearing is normal grossly. Lips, teeth and gums are normal with good dentition and no lesions. Oropharynx reveals no erythema, edema, exudate or lesions.
NECK: The neck appears normal with no tracheal deviation or JVD. Exam of the thyroid: no enlargement, assymetry or nodules
CHEST: Chest appears normal on inspection
PULMONARY: Respirations are normal with no signs of respiratory distress. Lungs are CTA B/L with no w/r/r
*CV: RRR, normal S1 and S2, no murmurs, rubs or gallops. Pedal pulses 2+ B/L. Extremities: no edema, varicosities or calf tenderness
*ABDOMEN: Soft, non-tender, normal active bowel sounds, no masses. No hepatomegaly or splenomegaly
* GU: Penis is normal in size, with no lesions. Scrotum normal with B/L descended testes and no masses
LYMPHATIC: Cervical lymph nodes normal B/L
MSK: Balanced gait. On palpation of the lumbosacral spine there was R paraspinal muscle tenderness, R sided muscle spasms. Flexion, particularly L lateral flexion, was restricted and painful. Palpation of joints and muscles is non-tender in UE and LE. No involuntary movements, no flacidity, no rigidity. Digits and nails are normal without clubbing, cyanosis or nail changes
NEUROLOGIC: Mental status is normal. No sensory loss in UE and LE B/L. Strength testing reveals 5/5 strength in UE and LE B/L
PSYCHIATRIC: Judgment and insight is normal throughout the exam. Patient is oriented to person, place and time. Mood and affect are normal throughout exam.
...PHYSICAL EXAM (cont)
Lower Back Pain 724.2
Plan?

-Xray?
-CT?
-Show off our OMM?
ACUTE LOW BACK PAIN
One of the most common doctor visits
85% of patients with isolated low back pain will never be given a specific anatomical reason for the pain
Up to 90% recover within 2 weeks of diagnosis
STEP 1: DIFFERENTIAL DIAGNOSES
97% MECHANICAL LBP
Lumbar strain, sprain 70%
Degenerative facets or disks 10%
Herniated disk 4%
Compression fracture 4%
Spinal stenosis 3%
Spondylolisthesis 2%
Spondylolysis <1%
1% NONMECHANICAL SPINAL CONDITIONS
Cancer (primary or metastatic) 0.7%
Inflammatory arthritis 0.3%
Infection 0.01%
2% VISCERAL DISEASE
Pelvic organs: prostatitis, PID, endometriosis
Renal disease: nephrolithiasis, pyelonephritis, perinephric abscess
Aortic aneurysm
GI Disease: pancreatitis, cholecystitis, peptic ulcer

Welp... that's a fairly broad initial differential for low back pain!
Yes... it is! The job of the healthcare provider is to consider:
is the pain caused by a systemic disease?
is it associated with a neurological compromise?
are there psychosocial factors that may lead to chronic back pain and thus complicate the recovery or efficacy of treatment?
Don't miss those
RED FLAGS
, too! (2° causes, underlying condition)
& Avoid unnecessary imaging, treatments, referrals
Unrelenting night pain
Unrelenting pain at rest
Neuromotor deficit
Unexplained fever
Greater than 6 weeks duration
Age >70
Loss of bladder or bowel control
Progessive focal neuro deficits
Suspicion of ankylosing spondylitis
Trauma
History or suspicion of cancer
Osteoporosis
Chronic corticosteroid use
Immunosuppression
Alcohol abuse
IV Drug use
A good history triages more serious back problems into those needing urgent attention and those that can be diagnosed more methodically
Hmmmmmm..... what's our initial assessment?
When a patient's examination is consistent with a localized musculoskeletal problem-
what's the best management?
Symptomatic therapies for 4-6 weeks, without imaging, with close follow-up in 1 month

Consider education in lifting and exercise therapy
Considering the entire clinical picture and 8/10 pain, we gave:
* Ketorolac Tromethamine 60 MG/2ML IM solution
* MethylPREDNISolone Acetate 40 MG/ML Injection suspension
* XR Lumbar Spine 5 views
FOLLOW-UP 12 DAYS FROM INITIAL VISIT
Patient returns with continued, unchanging pain
MR Lumbar: Several bulging discs from L1 to S1
ASSESSMENT
Lower Back Pain
Bulging Discs (L1-S1)
Closed compression fracture of L2 Vertebral Body
PLAN
CBC, CMP, Hemoglobin A1C, Lipid Panel, ESR, TSH
Referral: Neurosurgery evaluation & treatment
Physical Therapy requested
Lidoderm 5% External Patch, Tramadol HCl 50 MG BID
IMPORTANT CONSIDERATIONS
CAUDA EQUINA SYNDROME

Increasing neuro deficits, leg weakness, bowel & urinary incontinence, anesthesia/paresthesia in saddle distribution, B/L sciatica

PE: + straight leg raise test, reduction in anal sphincter tone, decrease ankle reflexes

Need immediate lumbar MRI, surgical decompression to prevent neuro deterioration
INFECTIOUS PROCESS
Fevers, direct vertebral tenderness, recent infections, history of IVDA
Ex: osteomyelitis, septic discitis, paraspinous abscess, epidural abscess

Evaluate by CBC, ESR, blood/abscess cultures, CSF and MRI

Require long courses of IV Antibiotics, sometimes surgical drainage
UNDERLYING CANCER
More likely if hx of cancer

Unexplained weight loss, worsening pain at night, no improvement after 1 month of therapy, age >50

CBC, ESR, plain radiographs
Evaluate further with MRI and/or bone scan

Cancers involving spine: Consider multiple myelomas, metastatic prostate, breast, lung, others
CASE PRESENTATION: FAMILY MED
HERNIATED DISC
Sciatica = classic sign = sharp, burning back pain w radiation down back & side of leg, distal to knee. Improves with lying down, increases with Valsalva, sneezing, coughing

Straight leg raise 91% sensitive, 26% specific
Sensory, strength, reflex testing of LE

>90% disc compression of nerve roots at L4/L5 & L5/S1
Majority have spontaneous improvement in first 2 weeks

MRI only if sx > 1 month or pt not candidate for surgery or epidural injection. Conservative tx w/ NSAIDS/acetaminophen, possible short course steroids, activity modifications.
Opioids only if severe pain & exhausted other tx options.


SPINAL STENOSIS
Congenital or acquired spinal canal narrowing
Puts pressure on spinal cord

Lower back & leg pain, leg weakness, pseudoclaudication after walking long distances
Majority have sx only when engaged in activities

More common in >60 yo, eval same as herniated disc

Tx: NSAIDS & analgesics, PT, epidural corticosteroids
MC in older people, osteoporosis or chronic steroid use
May occur after low impact trauma or no hx

Acute onset back pain after sudden movements (lifting, bending, coughing)

Pain often follows distribution of contiguous N, radiates B/L into ant abd aka "girdle of pain". Generally T12-L2

Generally thoracolumbar segment. Eval with Xrays.
Tx: with pain control, PT, calcitonin & bisphosphonates
balloon kyphoplasty

PSYCHOSOCIAL FACTORS
Eval for emotional distress, depression, fear avoidance (fear activity that will cause perm damage), job dissatisfaction, current involvement in litigation, somatization...

...are predictors for slow recovery & increase risk for chronic low back pain

Acknowledge & include tx of such factors
LUMBAR STRAIN
...what the vast majority have!

exact anatomical cause of pain unknown, possible incomplete tear in annulus fibrosis --> leak fluids --> inflammation or bulge posteriorly --> irritation of lumbar roots
Treatment of Acute Mechanical Back Pain
Acute = <4 weeks: tx centers on NSAIDS, acetaminophen, muscle relaxants, heat, early mobility
No significant benefit seen with opiates, systemic corticosteroids, or >2 d bed rest
Mod-Sev pain? Combo of muscle relaxant & NSAID more effective than monotherapy
Give muscle relaxants at nighttime due to sedative effects
Resume normal activities as tolerated
Massage therapy, spinal manipulation may be of some benefit for acute pain
PT has some benefit for short term relief, studies do not show long term benefit
Acupuncture and yoga may be reasonable options for chronic back pain, but effectiveness for acute back pain remains unproven
Prevention: Exercise. Lumbar support braces do not prevent back pain
FOLLOW-UP 5 DAYS FROM INITIAL VISIT
Many patients with LBP have
at least one red flag
(>80%)

Evaluate red flags in the context of the clinical presentation as a whole
VERTEBRAL COMPRESSION FRACTURES
OSTEOPATHIC MANIPULATIVE MEDICINE
SOFT TISSUE Prone pressure with counter leverage

COUNTERSTRAIN Posterior thoracic, posterior lumbars

MFR Lumbar (prone), Regional lumbosacral, lumbosacral direct decompression
BASIC PHYSICAL EXAM SHOULD INCLUDE:
Inspection of back and posture
Range of motion
Palpation of the spine
Straight leg raising (for patients with leg symptoms)
Neurologic assessment of L5 and S1 roots (for patients with leg symptoms)
Evaluation for malignancy (breast, prostate, lymph node exam) when persistent pain or history strongly suggests systemic disease
Assess peripheral pulses in those with exercise-induced calf pain
REFERENCES
Wheeler, Stephanie. Approach to the Diagnosis and Evaluation of Low Back Pain in Adults. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013.

Toy, Briscoe and Britton. Case 53: Low Back Pain. In: Case Files Family Medicine. 2013

WesternU OMM Technique Manual 2010-2011
Emily Utschig
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