Lower back pain: Difference between revisions

Revision as of 05:25, 19 February 2012

Background

Pain lasting >6wks is risk factor for more serious disease
Back pain in IV drug user is spinal infection until proven otherwise
Night pain and unrelenting pain are worrisome symptoms

Clinical Features

See Back Pain (Red Flags)
Musculoskeletal pain
- Located primarily in the back w/ possible radiation into the buttock/thighs
- Pain worse w/ movement but improves w/ rest
Spinal stenosis
- Bilateral sciatic pain worsened by walking, prolonged standing; relieved by forward flexion
Sciatica
- Refers to radicular back pain in the distribution of a lumbar or sacral nerve root
- Pain worsened by coughing, Valsalva, sitting; relieved by lying in supine position
- Occurs in only 1% of pts w/ back pain
- 95% of herniated disks occur at the L4-L5 or L5-S1 disk spaces

DDX

See Back Pain (DDX)

Work-Up

Pregnancy test
Exam
1. Straight leg raise testing
  1. Screening exam for a herniated disk (Sn 68-80%)
  2. Lifting leg causes radicular pain of affected leg radiating to BELOW the knee
  3. Pain is worsened by ankle dorsiflexion
2. Crossed Straight leg raise testing (high Sp, low Sn)
  1. Lifting the asymptomatic leg causes radicular pain down the affected leg
3. Nerve root compromise
X-rays (if have red flag)
1. Adults: AP + lateral of lumbar spine
2. Children: add oblique views (to evaluate for spondylolisthesis)
Labs
1. CBC/ESR/Chem 7/UA (if >50 yo)
MRI
1. Indications:
  1. 1. Suspect disk disease w/ severe motor impairment
    2. Suspect abscess or metastases w/ neuro involvement
Cauda equina syndrome
?Elevated ESR
US
1. Rule-out AAA

Source

Tintinalli

@@ Line 1: / Line 1: @@
 ==Background==
 *Pain lasting >6wks is risk factor for more serious disease
+*Back pain in IV drug user is spinal infection until proven otherwise
+*Night pain and unrelenting pain are worrisome symptoms
 ==Clinical Features==
+*See [[Back Pain (Red Flags)]]
 *Musculoskeletal pain
 **Located primarily in the back w/ possible radiation into the buttock/thighs
+**Pain worse w/ movement but improves w/ rest
+*Spinal stenosis
+**Bilateral sciatic pain worsened by walking, prolonged standing; relieved by forward flexion
 *Sciatica
 **Refers to radicular back pain in the distribution of a lumbar or sacral nerve root
-**Often accompanied by sensory or motor deficits
+**Pain worsened by coughing, Valsalva, sitting; relieved by lying in supine position
 **Occurs in only 1% of pts w/ back pain
 **95% of herniated disks occur at the L4-L5 or L5-S1 disk spaces
+[[File:Lumbar_Nerve_Root_Compromise.jpg]]
+==DDX==
+*See [[Back Pain (DDX)]]
 == Work-Up  ==
 #Pregnancy test
-#Straight leg raise testing
+#Exam
-##True sciatic tension should elicit pain before hamstrings are stretched enough to move the plevis
+##Straight leg raise testing
-#X-rays* (if have red flag)
+###Screening exam for a herniated disk (Sn 68-80%)
+###Lifting leg causes radicular pain of affected leg radiating to BELOW the knee
+###Pain is worsened by ankle dorsiflexion
+##Crossed Straight leg raise testing (high Sp, low Sn)
+###Lifting the asymptomatic leg causes radicular pain down the affected leg
+##Nerve root compromise
+#X-rays (if have red flag)
 ##Adults: AP + lateral of lumbar spine
 ##Children: add oblique views (to evaluate for spondylolisthesis)
 #Labs
 ##CBC/ESR/Chem 7/UA (if >50 yo)
+#MRI
+##Indications:
+####Suspect disk disease w/ severe motor impairment
+####Suspect abscess or metastases w/ neuro involvement
+#Cauda equina syndrome
+#?Elevated ESR
 #US
 ##Rule-out AAA
-=== CT/MRI Indications  ===
-#Suspect disk disease w/ severe motor impairment
-#Suspect abcess or mets w/ neuro involvement
-#Cauda equina syndrome
-#Elevated ESR
-== Red Flags  ==
-*See [[Back Pain (Red Flags)]]
-== DDX  ==
-*AAA
-*Cauda equina syndrome
-*Epidural abcess/hematoma
-*Spinal fracture with cord/nerve impingement
-*Back pain with neurologic def
-*Intervetebral disk herniation
-*Cancer
-*Meningitis
-*Sciatica
-*Spinal fracture
-*Spinal stenosis
-*Transverse myelitis
-*Vertebral osteo
-*Acute ligamentous injury
-*Acute muscle strain
-*Ankylosing spondylitis
-*Degeverative joint disease
-*Intervetebral disk disase
-*Pathologic fracture
-*Seropositive arthritis
-*Spondylolithesis
-*Cholecystitis
-*Esophageal disease
-*Pleural effusion
-*Pancreatic disease
-*Ulcer perforation
-*Retrocecal appendicitis
-*Large bowel obstruction
-*Renal disease
-*Pelvic disease
-*PID
-*Nephrolithiasis
-*PNA
-*PE
-*Pyelonephritis
-*Retroperitoneal hemorrhage/mass
-== Cord Compression  ==
-*L4
-**pain frnt leg, weak knee ext., sens. loss knee/medial foot, lose knee jerk.
-*L5
-**pain side leg, wk dorsiflex, sens. loss lat lo leg &amp; web big toe, reflex intact.
-*S1
-**pain back leg, weak plantarflex, sens. loss calf/lat foot, ankle jerk gone.
--Straight leg raise most sens., crossed most specific.
--Hypertrophic spur formation behind vert. is most likely non-disc cause of + SLR.
--Sciatica: impinged or irritated nerve. radicular distr., sharp, NO paresthesias/pain distal to knee/neuro impairment.
--Stenosis: back pain w/ walking, usually old person radiation to legs: Pseudo claudication. Usu. will curl after walking to get relief.
-== Treatment ==
-*Mild to mod:
-**NSAIDs
-*Mod to Severe
-**Non-narcotic(toradol/norflex), then 2-10 of MSO4 PRN
-**OPIOD (vicodin or percocet) &amp; nonsteroidal for 2-3 dy, then NSAID alone.
--#1 NSAIDs: ibuprofen, naprosyn; #2 Valium first choice for spasm as muscle relaxant. #3 Narcotics w/ oxycodone (percocet) 10-15 tabs. (don't use flexoril)
--Bedrest 2-3 days
--Referral
 == See Also  ==
 *[[Back Pain (Red Flags)]]
+*See [[Back Pain (DDX)]]
 == Source  ==
+*Tintinalli
-/26/06 DONALDSON (adapted from Rosen, Lampe, Hock)
 [[Category:Ortho]]