Description
To support your work with evidence bases references. As in all assignments, cite your sources in your work and provide references for the citations in APA format.
Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite sources in your responses to other classmates. In addition you must respond to your professor if applicable. Complete your participation for this assignment by the end of the week.
For this assignment, you will complete a Aquifer case study based on the course objectives and weekly content. Aquifer cases emphasize core learning objectives for an evidence-based primary care curriculum. Throughout your nurse practitioner program, you will use the Aquifer case studies to promote the development of clinical reasoning through the use of ongoing assessments and diagnostic skills and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice.
The Aquifer assignments are highly interactive and a dynamic way to enhance your learning. Material from the Aquifer cases may be present in the quizzes, the midterm exam, and the final exam.
Learn how to access and navigate Aquifer.
This week, complete the Aquifer case titled “Family Medicine 10: 45-year-old man with low back pain”
Apply information from the Aquifer Case Study to answer the following discussion questions:
Discuss the Mr. Payne’s history that would be pertinent to his genitourinary problem. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.
Describe the physical exam and diagnostic tools to be used for Mr. Payne. Are there any additional you would have liked to be included that were not?
Please list 3 differential diagnoses for Mr. Payne and explain why you chose them. What was your final diagnosis and how did you make the determination?
What plan of care will Mr. Payne be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?
Unformatted Attachment Preview
Family Medicine 10: 45-year-old male with low back pain
User: ARIADNA ZARZUELA
Email: ariadna.zarzuela@stu.southuniversity.edu
Date: October 11, 2023 11:54 PM
Learning Objectives
The student should be able to:
Recognize the societal and personal costs of acute and chronic back pain.
Conduct a focused history and physical exam appropriate for differentiating between common etiologies of a patient presenting with low back pain.
List risk factors for the development of low back pain.
Recognize “don’t miss” conditions that may present with low back pain.
Summarize the key features of a patient presenting with low back pain, capturing the information essential for differentiating between the common
and “don’t miss” etiologies.
Describe an evidence-based management plan that includes pharmacological and non-pharmacological treatment of acute LBP.
Find and apply a cost-effective diagnostic approach for common and “don’t miss” conditions in acute low back pain.
Knowledge
Low Back Pain Prevalence, Cost, & Duration
Low back pain (LBP) is the fifth most common reason for all doctor visits. In the U.S., the lifetime prevalence of LBP is 60% to 80%. The direct and
indirect costs for treatment of LBP are estimated to be $100 billion annually. Fortunately, most LBP resolves in two to four weeks.
Common Causes of Back Pain
Musculoskeletal (MSK) and Non-MSK Causes of Back Pain
MSK Causes
Axial:
Degenerative disc disease
Facet arthritis
Sacroiliitis
Ankylosing spondylitis
Discitis
Paraspinal muscular issues
SI dysfunction
Radicular:
Disc prolapse
Spinal stenosis
Trauma:
Lumbar strain
Compression fracture
Non-MSK Causes
Neoplastic:
Lymphoma/leukemia
Metastatic disease
Multiple myeloma
Osteosarcoma
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Inflammatory:
Rheumatoid Arthritis
Visceral:
Endometriosis
Prostatitis
Renal lithiasis
Infection:
Discitis
Herpes zoster
Osteomyelitis
Pyelonephritis
Prostatitis
Spinal or epidural abscess
Vascular:
Aortic aneurysm
Endocrine:
Hyperparathyroidism
Osteomalacia
Osteoporotic vertebral fracture
Paget disease
Gastrointestinal:
Pancreatitis
Peptic ulcer disease
Cholecystitis
Gynecological:
Endometriosis
Pelvic inflammatory disease
Most Common Causes of Back Pain
There are three major categories of back pain: mechanical, visceral, and non-mechanical.
Mechanical
97% of back pain
No primary inflammatory or neoplastic cause
Visceral
2% of back pain
No primary involvement of the spine, usually from internal organs
Non-mechanical
1% of back pain
Other
The three most common causes of back pain are all mechanical:
1. Lumbar strain/sprain – 70%
2. Age-related degenerative joint changes in the discs and facets – 10%.
3. Herniated disc – 4%
Acute sciatica is lower back pain with radiculopathy below the knee and symptoms lasting up to six weeks. Sciatica is a common and costly problem,
caused by a variety of conditions: disc herniation, lumbar spinal stenosis, facet joint osteoarthritis or other arthropathies, spinal cord infection or
tumor, or spondylolisthesis.
Less common causes of mechanical back pain:
Osteoporotic fracture – 4%
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Spinal stenosis – 3%
Uncommon causes of back pain:
Pyelonephritis, a visceral cause, accounts for 0.4% of back pain.
Risk Factors for Low Back Pain
Prolonged sitting, with truck driving having the highest rate of LBP, followed by desk jobs
Deconditioning
Sub-optimal lifting and carrying habits
Repetitive bending and lifting
Spondylolysis, disc-space narrowing, spinal instability, and spina bifida occulta
Obesity
Prolonged use of steroids
Intravenous drug use
Education status: low education is associated with prolonged illness
Psycho-social factors: anxiety, depression, stressors in life
Occupation: Job dissatisfaction, increased manual demands, and compensation claims
Red Flags For Serious Illness or Neurologic Impairment with Back Pain
Fever
Unexplained weight loss
Pain at night
Bowel or bladder incontinence
Urinary retention
Neurologic deficits
Saddle anesthesia
Trauma
Anatomy of Mechanical Lower Back Pain
Mechanical lower back pain generally involves one or more of the following:
1. Bones of the spine
2. Muscles and ligaments surrounding the spine
3. Nerves (the nerves entering and exiting the spinal cord or problems with the cord itself)
Symptoms of Disc Herniation
When disc herniation is suspected, a very important historical point is the position of comfort or worsening of symptoms.
Classically, disc herniation is associated with exacerbation when sitting or bending; and relief while lying or standing.
Other symptoms of disc herniation include:
Increased pain with coughing and sneezing
Pain radiating down the leg and sometimes the foot
Paresthesias
Muscle weakness, such as foot drop
Red Flags for Serious Underlying Causes of Back Pain
While the majority of back pain has a benign course and resolves within a month, a small number of cases are associated with serious underlying
pathology. Timely treatment of these conditions is important to avoid serious consequences. Indications for early diagnostic testing such as x-rays
and other imaging and referral are patients with progressive neurological deficits, patients not responding to conservative treatment, and patients
with red flags signaling serious medical conditions such as fracture, cancer, infection, and cauda equina syndrome. Knowing this would also help
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guide the evaluation and treatment of back pain.
While the worst pain a patient has ever had is concerning and needs to be addressed, it is not by itself indicative of a more serious condition.
Numbness can be part of cauda equina, but is also common with a simple disc herniation, therefore by itself it is not a red flag.
Red Flags by Serious Condition
Cancer
1. History of cancer
2. Unexplained weight loss > 10 kg within 6 months
3. Age over 50 years or under 17 years old
4. Failure to improve with therapy
5. Pain persists for more than 4 to 6 weeks
6. Night pain or pain at rest
Infection
1. Persistent fever (temperature over 38 °C (100.4 °F))
2. History of intravenous drug abuse
3. Recent bacterial infection, particularly bacteremia (UTI, cellulitis, osteomyelitis, endocarditis, pneumonia, or pelvic inflammatory disease)
4. Immunocompromised states (chronic steroid use, diabetes, HIV, taking chemotherapeutic or biologic medications)
Cauda Equina Syndrome
1. Urinary incontinence or retention
2. Saddle anesthesia
3. Anal sphincter tone decreased or fecal incontinence
4. Bilateral lower extremity weakness or numbness
5. Progressive neurologic deficits
Significant Herniated Nucleus Pulposus
1. Major muscle weakness (strength 3 of 5 or less)
2. Foot drop
Vertebral Fracture
1. Prolonged use of corticosteroids
2. Mild trauma over age 50 years
3. Age greater than 70 years
4. History of osteoporosis
5. Recent significant trauma at any age (car accident, fall from substantial height)
6. Previous vertebral fracture
Acute Low Back Pain Prognosis
Most cases of low back pain are acute in onset and resolution, with 90% resolving within one month and only 5% remain disabled longer than three
months.
For patients who are out of work greater than six months, there is only 50% chance of them returning to work; this drops to almost zero chance if
greater than two years.
Patients who are older (> 45) and patients who have psychosocial stress take longer to recover.
Recurrence rate for back pain is high at 35 to 75%.
Clinical Skills
Recommended Low Back Pain History
1. History of present illness.
What is the location of the pain? Is it upper, middle, or lower back? Left or right side?
What is the duration of the pain or how long ago did it start? Is it getting worse or better? Does the pain radiate? Pain that radiates below the
knee- more consistent with sciatica; pain around the buttock- more consistent with a lumbar strain.
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What is the severity of the pain? Use a pain scale of 0 to 10 to make the severity somewhat more objective. Intensity of the pain.
What is the quality of the pain? Is it achy, or sharp, or dull, or throbbing?
Is the pain constant or intermittent? If intermittent, how often does it occur? How long does it last? Is it present at night or at rest?
Are there associated symptoms (such as fever, weight loss, weakness, numbness, tingling)?
Are there aggravating or alleviating factors? Aggravating circumstances (active vs. passive motion, day vs. night). Valsalva can increase pain
from a herniated disk. Alleviating circumstances (medication, positioning-sitting, lying, standing). What has the patient tried to relieve the
problem (what worked, what didn’t)?
Any history of similar problems?
2. Pertinent past history. Recent illnesses, history of recent trauma or injury, patient’s occupation, previous history of a back injury, history of back
surgery, cancer, or DM. (Fatigue is a nonspecific finding which may not help you to narrow your differential diagnosis.)
3. Review of systems. In order to narrow your differential diagnosis for the patient’s problem, a review of systems focused on pertinent positives and
negatives is important.
Neurologic symptoms: saddle anesthesia, lower extremity numbness, tingling, muscle weakness particularly in the lower extremities, fecal
incontinence
Urinary symptoms: urinary incontinence, urinary retention, hesitancy, frequency, dysuria
Gastrointestinal symptoms: nausea, vomiting, hematemesis, hematochezia, constipation, diarrhea, acid reflux symptoms
Constitutional symptoms: fever, unexplained weight loss
4. Current medications and allergies
Approach to the Physical Exam for Back Pain
Perform the back exam systematically in sequential order with the patient:
1. Standing
2. Sitting
3. Supine
Physical Exam for Back Pain—Standing
Throughout the whole exam make certain to note how your patient is sitting, standing, and walking in general, asking yourself, “What is his degree of
impairment?” and “How uncomfortable is he?”
I. Inspection: Look at posture, contour, and symmetry. Also, inspect overlying skin to check for any lesions or abnormalities.
Check for lordosis
Check for kyphosis
Check for scoliosis
Slight scoliosis may be more easily visualized during lumbar flexion. This is performed by having the patient stand with their feet and hands together,
like they are about to dive off a diving board, bending forward toward their toes. Look out across the back to see if the shoulders are level.
II. Palpation: Check for any tenderness, tightness, rope-like tension, or inflammation in the paraspinous muscles or tenderness over bony
prominences. This procedure checks for muscle spasms, vertebral fractures, or infection.
III. Range of Motion (ROM):
Lumbar Flexion (normal is 90 degrees): This is the best measure of spine mobility. Restriction and pain during flexion are suggestive of
herniation, osteoarthritis, or muscle spasm.
Lumbar Extension (normal is 15 degrees): Pain with extension is suggestive of degenerative disease or spinal stenosis.
Lateral Bending (normal is 45 degrees): Most patients should be able to touch the proximal fibular head of the knee. Pain on the same side as
bending is suggestive of bone pathology, such as osteoarthritis or neural compression. Pain on the opposite side of bending is suggestive of a
muscle strain.
Rotation to the left and rotation to the right. Compare side to side.
Range of motion may be varied due to the patient’s age and body habitus
IV. Gait: Ask the patient to walk on heels and toes. Expect normal gait, even with disc herniation.
Difficulty with heel walk is associated with L3-L4 disc herniation/L4 nerve root
Difficulty with toe walk is associated with L5-S1 disc herniation/S1 nerve root
V. Stoop Test: Have the patient go from a standing to squatting position.
In patients with central spinal stenosis, squatting will reduce the pain. However, asking the patient to run is not part of a back exam and may cause
discomfort to the patient who is already in pain.
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Disk L3-L4, Nerve root L4, Patellar Reflex, Motor examination: Ankle dorsiflexion
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Disk L3-L4, Nerve root L4, Patellar Reflex, Sensory loss signature zone: Medial malleolus
Disk L4-L5, Nerve root L5, Reflex: none, Motor examination: Great toe dorsiflexion
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Disk L4-L5, Nerve root L5, Reflex: none, Sensory loss signature zone: Dorsal third metatarsophalangeal joint
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Disk L5-S1, Nerve root S1, Reflex: Achilles, Motor examination: Ankle plantar flexion
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Disk L5-S1, Nerve root S1, Reflex: Achilles, Sensory loss signature zone: Lateral heel
Physical Exam for Back Pain—Seated Position
Overview of the Neurologic Exam
Deep Tendon Reflexes
Grading Reflexes:
0 No evidence of contraction
1+ Decreased, but still present (hyporeflexic)
2+ Normal
3+ Increased (hyperreflexia)
4+ Clonus: Repetitive shortening of the muscle after a single stimulation
Decreased patella reflex implies nerve impingement at the L3-L4 level/L4 nerve root. Decreased Achilles reflex implies nerve impingement of L5-S1
level/S1 nerve root. Hyperreflexia is a sign of upper motor neuron syndrome associated with spinal cord compression.
Muscle Strength
Rating Scale:
0/5 No movement
1/5 Barest flicker of movement of the muscle, though not enough to move the structure to which it’s attached
2/5 Voluntary movement, which is not sufficient to overcome the force of gravity. For example, the patient would be able to slide their hand across a
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table but not lift it from the surface.
3/5 Voluntary movement capable of overcoming gravity, but not any applied resistance. For example, the patient could raise their hand off a table,
but not if any additional resistance were applied.
4/5 Voluntary movement capable of overcoming “some” resistance
5/5 Normal strength
i. Hip Flexion (L 2, 3, 4): Ask the patient to lift his thigh while you push down on his thigh
ii. Hip Abduction (L 4, 5, S1): Ask the patient to push his legs apart while you push them together
iii. Hip Adduction (L 2, 3, 4): Ask the patient to push his legs together while you push them apart
iv. Knee Extension (L 2, 3, 4):
Ask the patient to extend their knee while you push it down.
v. Knee Flexion (L 5, S1, S2):
Ask the patient to flex his knee while you push against it.
vi. Ankle Dorsiflexion (L 4, 5): Ask the patient to point his foot up while you push it down.
vii. Ankle Plantar Flexion (S 1, S 2): Ask the patient to point his foot down while you push it up.
Decreased strength implies nerve impingement of the associated nerve in parenthesis.
Sensation
Test for sharp and light touch along dermatomal distribution, great toe (L5), lateral malleolus, and posteriolateral foot (S1)
Nerve Root Impingement Syndromes
Nerve Root Reflex
Pin-Prick Sensation
Motor Examination Functional Test
L3
Patellar tendon reflex Lateral thigh and medial femoral condyle
Extend quadriceps Squat down and rise
L4
Patellar tendon reflex Medial leg and medial ankle
Dorsiflex ankle
Walk on heels
L5
Medial hamstring
Dorsiflex great toe
Walk on heels
S1
Achilles tendon reflex Posterior calf, sole of foot, and lateral ankle Stand on toes
Lateral leg and dorsum of foot
Walk on toes (plantarflex ankle)
Check for costovertebral angle (CVA) tenderness, a sign suggesting pyelonephritis.
Modified version of the straight leg raise (SLR) test
While continuing to talk to the patient, raise each leg by extending the knee from 90 degrees to straight. If the pain is due to structural disease, the
patient will instinctively exhibit the “tripod sign” by leaning backward and supporting himself with his outstretched arms on the exam table.
(The unmodified version of the straight leg raise (SLR) test is done in the next section of the exam with the patient supine.)
Neurological exam
Check reflexes, muscle strength, and sensation of the lower extremities. Focus on the L4, L5, and S1 nerve roots because most neuropathic back
pain is due to impingement of these. Therefore, check the patellar reflex (L2-4) and Achilles reflex (S1). Check muscle strength for hip flexion,
abduction, and adduction; knee extension and flexion; as well as ankle dorsiflexion and plantar flexion. Also, test for sharp and light touch along the
dermatomal distribution of the great toe (L5), lateral malleolus, and posterolateral foot (S1).
Physical Exam for Back Pain—Supine
I. Abdominal Exam
Auscultation: Check for abdominal bruit, looking for abdominal aortic aneurysm.
Palpation: Check for abdominal tenderness (on all patients, not just female patients), pelvic tenderness (pelvic inflammatory disease),
pulsatile mass, unequal femoral/brachial pulses (abdominal aortic aneurysm), or any general tenderness indicating visceral pathology.
II. Rectal Exam
To be done only on patients with red flags or alarm symptoms, which we will discuss later!
Check for masses, bleeding, or abnormal rectal tone. Bleeding or rectal mass can be signs of cancer with metastasis to the spine causing
back pain. Decreased tone can indicate disc herniation and/or cauda equina syndrome.
III. Passive Straight Leg Raise (SLR or Lasegue’s sign)
The normal leg can be raised 80 degrees.
If a patient only raises their leg < 80 degrees, they have tight hamstrings or a sciatic nerve problem.
To differentiate between tight hamstrings and a sciatic nerve problem, raise the leg to the point of pain, lower slightly, then dorsiflex the foot. If
there is no pain with dorsiflexion, the patient's hamstrings are tight.
The test is positive if pain radiates down the posterior/lateral thigh past the knee. This radiation indicates stretching of the nerve roots
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(specifically S1 or L5) over a herniated disc.
This pain will most likely occur between 40 and 70 degrees.
IV. Crossed Leg Raise : asymptomatic leg is raised
Test is positive if pain is increased in the contralateral leg; this correlates with the degree of disc herniation. Such results imply a large central
herniation.
Cross SLR test is much less sensitive (0.25) but is highly specific (about 0.90). Thus, a negative test is nonspecific, but a positive test is virtually
diagnostic of disc herniation.
V. FABER Test: Flexion, Abduction, and External Rotation
The Faber test looks for pathology of the hip joint or sacrum (sacroiliac pain from sacroiliitis).
The test is performed by flexing the hip and placing the foot of the tested leg on the opposite knee. Pressure is then placed on the tested knee
while stabilizing the opposite hip.
The test is positive if there is pain at the hip or sacral joint or if the leg cannot lower to the point of being parallel to the opposite leg from the
pathology of the hip, sacrum, or sacroiliac joint.
The FABER test should be done on all patients suspected of having sacroiliac pain, not just in the older adult patients. Sacroiliitis can occur in the
young population as well.
VI. Muscle Atrophy: of quadriceps and calf muscles.
Management
Conservative Therapy for Acute Low Back Pain
Initial conservative therapy for acute low back pain includes:
Pharmacologic therapy: Aspirin/NSAID
Local therapy: Local therapy (heat/cold). Learn more about local therapy here.
Activity: Advice to stay active and/or sending patients to physical therapy may help prevent recurrence.
Pharmacologic therapy: The first-line medications for the treatment of LBP are non-steroidal anti-inflammatory drugs (NSAIDs). Recent evidence
shows that acetaminophen, is no better than placebo, though in patients that cannot tolerate NSAIDs it may be the best option to try. Systematic
reviews of randomized controlled studies found moderate evidence that NSAIDs are helpful in the treatment of acute LBP.
As second-line therapy, a nonbenzodiazepine muscle relaxant such as cyclobenzaprine can be added. There is debate as to their effectiveness. A
2003 systematic review found them to be effective, but a 2021 meta-analysis found that there was only a small benefit. Muscle relaxants are a
diverse group of medications, but all have side effects such as sedation and anticholinergic effects.
There is little evidence regarding the benefits of opioid use in LBP, and there is significant concern about the risk of the development of addiction.
Occasionally, when pain cannot be controlled in other ways or when there are contraindications to other options, opioids are prescribed. Such
prescriptions should be time-limited. No studies support the use of oral steroids in patients with LBP.
Learn more about activity here and here.
Strict bed rest has been shown to prolong recovery. Patients should be encouraged to resume normal activities as soon as they are able to.
Referral to a surgeon or advanced imaging, such as MRI/CT scans, should be entertained if back pain is not better in four to six weeks or if
progression of neurologic deficits is demonstrated. The "Choosing Wisely" campaign in family medicine has good patient resource material to explain
the recommendation to wait for imaging.
Effectiveness of Physical Therapy for Acute Back Pain
There is some data to show that tailored physical therapy is slightly more effective for acute back pain compared to patients who just stay active. At
four weeks, patients who received physical therapy had 10-point improvement in a 100-point disability score compared to the control group. There is
great variation in physical therapy because various interventions (exercises, traction, massage) and different modalities (heat, ice, ultrasound) may
be used. There is also evidence that spinal manipulation is safe and can help in the short term.
Low Back Pain Treatment After Adequate Trial of Conservative Therapy
If a patient has been in pain for five weeks with a progression of neurological deficit (such as absent reflex at the ankles) and poor pain control, it is
reasonable to refer him to a spine surgeon for surgical consultation.
If the patient doesn't have any red flags, the continuation of conservative treatment is also an option. However, if the patient has already been getting
PT, more PT is not likely to help.
There is some evidence that acupuncture can be helpful in low back pain.
The benefit of epidural injections of glucocorticoids is uncertain in this case. The clinical benefits in randomized trials are minimal, and a recent study
compared with sham injection and oral gabapentin showed no benefit of epidural steroid injections at three months. Despite the weak evidence, this
intervention is still frequently recommended so as to avoid surgery.
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Studies
Indications for Studies to Evaluate Low Back Pain
Laboratory tests generally are not needed in the evaluation of acute low back pain.
CBC
CBC, sedimentation rate (ESR), and C-reactive protein (CRP) should be ordered if tumor or infection is suspected.
X-ray
Agency for Health Care Policy and Research (AHCPR) guidelines for x-ray:
History of trauma
Strenuous lifting in patient with osteoporosis
Prolonged steroid use
Osteoporosis
Age < 20 and > 70
History of cancer
Fever/chills/weight loss
Pain worse when supine or severe at night
Spinal fracture, tumor, or infection
The American College of Radiology (ACR) has appropriateness criteria for imaging for various conditions. View the ones for low back pain (.pdf).
Lumbar spine film
Lumbar spine films are commonly used, but lack specificity and have a high rate of false-positive findings. Patients with symptoms and pathology
may have an apparently benign x-ray and asymptomatic patients may have abnormal x-rays.
MRI
An MRI is indicated if the following are present:
Worsening or unremitting neurologic deficit or radiculopathy
Progressive major motor weakness
Cauda equina compression (sudden bowel/bladder disturbance)
Suspected systemic disorder (metastatic or infectious disease)
Failed six weeks of conservative care
However, 75% of herniated discs improve with six weeks of conservative therapy. MRI testing is not associated with clinical benefit in randomized
trials. Early MRI is not associated with improved outcomes in patients with acute back pain or radiculopathy (Level 2/mid-level evidence). If surgery
is being considered, some physicians recommend, in the absence of red flags, obtaining an imaging study after one month of symptoms.
Electrodiagnostics-Electromyography
Electrodiagnostics-Electromyography (EMG) and nerve conduction studies can be used in the evaluation of patients with radicular pain and lumbar
spinal stenosis.
Electrodiagnostic tests are useful to confirm the existence of radiculopathy (level of nerve involvement) and to exclude the presence of other
peripheral nerve disorders. Electrodiagnostic tests are time-sensitive because nerve root abnormalities may not be reliably detectable until three
weeks after the onset of symptoms. They are particularly useful as an adjunct to clinical evaluation and imaging in the following two clinical scenarios:
physical examination does not correlate with imaging studies, and to clarify the functional significance of an imaging abnormality.
Assessment of Acute Back Pain
In the absence of red flags or findings suggestive of systemic disease, diagnostic testing, especially imaging, is not indicated until after four to six
weeks of conservative treatment. Ordering tests too early is not only cost-ineffective but can also cause harm to the patient.
Spine x-rays expose patients to radiation. This is particularly concerning in younger women because the radiation exposure to the ovaries in a single
plain radiograph of the lumbar spine is equal to getting a daily chest x-ray (CXR) for approximately 75 days.
CT scans expose patients to contrast materials that have renal toxicity, and even higher doses of radiation. Routine imaging of the back using CT or
MRI is not associated with improved outcomes and may identify abnormalities that are unrelated to the patient’s back pain. This can cause anxiety
and could lead to more testing and possibly unnecessary intervention.
Algorithm for assessment of acute back pain .
Clinical Reasoning
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Differential for Low Back Pain
The most common cause of acute low back pain in adults
Typically has an acute or sub-acute onset after an injury or precipitating activity (e.g., moving furniture)
Lumbar strain
Pain is typically worse in the paraspinal muscles lateral to the spine and may be bilateral or unilateral
Pain may radiate down one or another leg
Pain is worse after periods of immobility and with particular movements (depending on where the strain is)
May have acute or sub-acute presentation
May be precipitated by a sudden injury
Disc herniation
Pain is often worse when the hips are flexed, as in sitting
Location of pain depends on the level of the herniation
Increasingly common with advancing age
Degenerative
arthritis
If an osteophyte impinges a nerve root can cause radicular symptoms in that nerve’s distribution
Has a more insidious onset
Caused by central deformity compressing the cord, such as by central disc herniation, spondylolisthesis, osteophyte, or
mass
Spinal stenosis
Hallmark symptom is pain radiating to the legs (bilateral more common than unilateral) that is brought on by walking or
standing (sometimes called pseudoclaudication)
Sitting relieves the symptoms
Not likely without a history of trauma.
Spinal fracture
Bony point-tenderness in a patient with low back pain should prompt an x-ray to evaluate for fracture
Should always be considered due to the seriousness of the consequences.
Cauda equina
syndrome
Occurs when a large mass effect (such as an acute disc herniation or a tumor) compresses the cauda equina, causing pain
radiating down the leg and can be accompanied by weakness and numbness of the leg.
True emergency. Decompression should be performed within 72 hours to avoid permanent neurologic deficits.
Low on the differential if the patient denies problem with bowel or bladder control.
Pyelonephritis
Unlikely with lack of fever and urinary symptoms.
Important consideration. A very serious, although uncommon, cause of back pain.
Unlikely without a history of cancer.
Malignancy
Back pain due to malignancy is localized to the affected bones, it is a dull, throbbing pain that progresses slowly, and
it increases with recumbency or cough .
More commonly seen in patients over 50.
Ankylosing
spondylitis
Chronic, painful, inflammatory arthritis primarily affecting the spine and sacroiliac joints, causing eventual fusion of the
spine.
Often seen in patients 15-40 years old, associated with morning stiffness and achiness over the sacroiliac joint and
lumbar spine.
Anterior displacement of a vertebra or the vertebral column in relation to the vertebrae below.
Spondylolisthesis
Can occur at any age.
Causes aching back and posterior thigh discomfort that increases with activity or bending .
Can cause referred LBP in men.
Prostatitis
(Pelvic inflammatory disease and endometriosis in women can cause referred LBP).
Expect to find evidence of infection in the history.
© 2023 Aquifer, Inc. – ARIADNA ZARZUELA (ariadna.zarzuela@stu.southuniversity.edu) – 2023-10-11 23:54 EDT
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Pancreatitis and other gastrointestinal diseases such as cholecystitis and ulcers can cause LBP via visceral pain.
Pancreatitis
Usually associated with other abdominal symptoms.
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