# 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

    ​
