Back Pain

Overview

Alarming symptoms

• alarming symptoms:

  • bowel, bladder incontinence

  • saddle anesthesia

  • any FND that's new or rapidly progressing

Workup

Someone comes in with lower back pain:

• if alarming symptoms, think cord compression:

  • Give IV steroids ASAP

  • Xray or jump to MRI if giving steroids

  • Decompress the compression

    • hematoma: drain

    • abscess: incision drainage + abx

    • cancer: radiation

    • fracture: surgery

• if nonspecific, vague complaints, think musculoskeletal pain:

  • NSAIDS, exercise

  • Do not pick bedrest

  • No imaging needed

  • reassess in 4 weeks

    • improvement: continue

    • failed improvement or if positive symptoms: something else

      • Xray

      • if negative Xray, MRI

      • some form of surgery

Cord Compression

• causes

  • Spinal injury (eg, motor vehicle crash)

  • Malignancy (eg, lung, breast, prostate cancers; myeloma)

  • Infection (eg, epidural abscess with IV drug users or diabetes)

• Symptoms

  • Gradually worsening, severe local back pain

  • Pain worse in the recumbent position/at night

  • Early signs: Symmetric lower extremity weakness, hypoactive/absent deep-tendon reflexes

  • Late signs: Bilateral Babinski reflex, decreased rectal sphincter tone, paraparesis/paraplegia with increased deep-tendon reflexes, sensory loss

Most patients present with progressively worsening back pain. Pain is usually worse in the recumbent position (due to distension of the epidural venous plexus when lying down) in contrast to back pain from degenerative joint disease, which improves with recumbency. Bilateral lower-extremity weakness is present in about 60% of patients. Sensory loss below a spinal level and gait ataxia may occur. Paraplegia and bowel or bladder dysfunctions (eg, fecal or urinary retention/incontinence) are late findings. Examination shows focal point tenderness in the spine, exaggerated deep-tendon reflexes in the legs, and upgoing plantar reflexes.

In the acute phase of spinal cord injury, patients can develop spinal shock and have absence of reflexes and flaccid paraplegia.

Management

• Emergency MRI

• Intravenous glucocorticoids

• Radiation-oncology & neurosurgery consultation

• infarction: rapid onset

• compression: slow progressive onset

MSK Pain

• path: muscle spasm

• pt: young, male, heavy lifting

• symptoms: back hurts, no alarming symptoms, "delt like," asymmetric/unilateral

• diagnosis: clinical

• treatment: exercise, NSAIDS.,

Something Else

Disc Herniation

• path: nucleus pulposus pinching nerve

• pt: 30-50 yo male, heavy lifting

• symptoms: sciatica, lightning shock pain down leg, positive straight leg test

• diagnosis: Xray probably negative, MRI next

• treatment: depends on severity/lifestyle

  • neurosurgery > conservative at 6 mo (probably atheletes)

  • neurosurgery = conservative at 1 yo (probably older guy just wants to live).,

Osteophyte

• path: bony spur growing into canal and pinches nerve

• pt: older male, no heavy lifting

• symptoms: asymmetric, unilateral, sciatica, + SLR

• diagnosis: Xray probably negative, MRI showing bone spur

• treatment: surgery. Not going to get better with conservative

Compression Fracture

• path: osteoporosis

• pt: >50, female, falls

• symptoms: vertebral step-off, pinpoint tenderness

• diagnosis: xray probably positive, MRI better

• treatment: surgery, dexa scan for osteoporosis.,

Spinal Stenosis

• path: narrowing of canal, pinching of nerve

• pt: old, male or female

• symptoms: pseudoclaudication in butt/thighs, positional (claudication when walking around upright)

• diagnosis: xray probably negative, MRI better

• treatment: surgery, laminectomy.,

Others

• women in menstrual cycle with lower back pain, treatment with NSAIDS

• back pain with abdominal pulsating mass: aortic aneurysm

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