approach a patient with low back pain
TRANSCRIPT
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How to approach a patient with low back pain
DONE BY: Al-Yaqdhan Al-AtbiSenior clerckship student
SQUH
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• History• Physical examination• Investigations• Management
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Case …
Mr. B is a relatively healthy 37 years old male. While working in his yard, he experienced intense lower back pain that prevented him from doing any more work. He used some ibuprofen for pain relief and spent the remainder of the day resting. The next morning he had increased muscle stiffness and was not feeling any better, so he come to see you.
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What do you want to ask Mr.B?
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• Personal data
• Present complain
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Present complain
• Onset & how it start :• acute or chronic• What were you doing just before the pain began? • Did you have a particular injury or accident?
• Character:
Sharp, dull, throbbing or burning ??
• Location & radiation:• lumber strain .. Paraspinous muscles- buttock• Herniated disc .. Below the knee
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• Duration• < 6wk Acute• 6-12 wk Subacute • > 12 wk Chronic
• Intensity• How it effects daily activity?• Interfere with sleeping, walking or driving ?
• Associated symptoms• stiffness, urinary or abdominal symptoms ??
Present complain
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• Aggravating factors• Valsalva maneuvers• Sitting• Walking down-staires
• Relieving factors• Medication• Non-pharmacologic measures ( massage, stretching,
heat or ice)• Certain position.
Present complain
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MR. B
He describe the pain as dull and burning. There is some radiation into the left buttock. Prolong sitting or moderate activity aggravate the pain. He can get relief when he lies down. He has never had back pain like this.
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• Fever ??• Appetite/ wt loss?• Abdominal pain?• Cough/ sputum? • Bowel habits?• Dysuria, Hematuria?• Menestural history?
Systemic review
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• Medical & surgical history:– Previous trauma– Kidney diseases– Previous back pain, therapy– Malignancy– Disc prolepses—surgery– Female---obstrict diseases
• medication?? • Corticosteroids , immunosuppressant
past medical history
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Family history
• Cancers • Back pain • Spondylarthropathie
s
Social history• Current stresses• Occupation:
• Work, job tasks.• Activity level of the job
• Perception of the pain ,impact on life
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In Evaluating Patient With Low Back pain Should Remember :
• Determine that the pain is intrinsic to the back and not referred from problem elsewhere.
• Rule out progressive and Life- threatening disease.
• Determine whether nerve root compromise is present or not.
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Red flags
General•Failure to improve after 4-6wk of conservative therapy•Unrelenting night pain or pain at rest•Progress motor or sensory deficit
Cancer•Age > 50 •History of cancer or current cancer•Unexplained weight loss
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Infection•Fever or chills•Recent infection .. UTI or skin•Immunosuppression• IV drug use
Fracture•Age > 50 •History of osteoporosis•Significant trauma•Chronic oral steroid use
Red flags
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Cauda Equina S.
•Urinary incontinence or retention•Saddle anesthesia •Decrease anal tone or fecal incontinence•Lower extremities weakness
AAA•Age > 60 •Abdominal pulsating mass •Pain at rest
Red flags
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Physical examination
• General appearance• Vital sings• Back examination• Systemic examination
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• GENERAL APPERANCE :• Comfortable or not ?• Sitting, standing or leaning on something?
• Vital sing • Record vital sings• High Temp. ???
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Back examination• look• Feel• Move• Special tests
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Look:• From side:
• evaluate spinal curvatures.• From behind:
• Note any scars, swelling, erythema.• Shape of the spine.
Feel:• The spinous processes of each vertebra.
– Tenderness .. Fracture, dislocation , infection or arthritis• Any step-offs
– in spondylolisthesis or forword slipping of one vertebra, which may compress the spinal cord.
• Muscle spasm or tenderness– degenerative or inflammatory process , prolong contraction from
abnormal posture or anxiety.• Sacroiliac joint
– tenderness indicate sacroiliitis or ankylosing sponylitis
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MOVE
Flexion Extension
Rotation Lateral bending
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Special Tests
• Scobar’s test: – measure forward flexion of the spine
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Straight leg raising Test
• How: • Ask the patient to lie down on their back. • Have the patient completely relax the affected leg. • Cup the heel of their foot and gently raise the leg .
• Positive test:– Sciatic pain at 30-70 degree– Aggravation of pain dorsiflexion of
the foot– Relief of pain by knee flexion
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• The straight leg raising test.• if positive indicates lumber nerve root compromise.
• The crossed straight leg raising test.(pain radiate into opposite leg)
• if positive indicates disc herniation.
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Examination of the lower limb
• Muscle strength:• Hip:
» Flexion (L2, 3,4 )» Adduction (L2, 3,4 )» Abduction ( L4, L5, S1 )» Extension (SI)
• Knee» Extension at the knee (L2,L3,L4)» Flexion at the knee (L4,L5,S1,S2 )
• Dorsiflexion ( mainly L4,L5) • planter flexion (mainly S1).
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• Deep tendon reflexes:– The knee reflex (L2,L3,L4)
The Ankle reflex (S1) The planter response(L5,S1)
• Gaite• Walk on heel ( L5)• Walk on toe (S1)
Examination of the lower limb
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• Uncomfortable, prefer to stand.• Has full ROM excep for limited forward
flexion• Tenderness on paraspinous muscles.• SLR & crossed SLR test are negetive.• Lower limb:
– Normal reflexes, strength and sensation.
MR. B
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• What investigations you will order for MR.B ??
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• MOST PATIENTS WITH LOW BACK PAIN DO NOT NEED INVESTIGATIONS
-Majority not due to a serious underlying condition
-Most are self-limited
70% to 90% of acute Low Back Pain cases will Resolve in 1 month
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Investigations
• Radiological imaging
1. X-ray
2. MRI
3. CT
4. Radionuclide (bone scan)
• Laboratory tests
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Plain X-ray
Are very commonly used for low back pain
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Do not X-ray routinely
Required only if the pain is associated with red flag signs, which indicate a high risk of more serious
underlying problems
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Do not X-ray routinely
• EXCEPTIONS:
1. Young(<25) X-ray sacroiliac joint to exclude ankylosing spondylitis
2. Elderly: to exclude vertebral collapse/malignancy; history of trauma; ‘red flag’ signs
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Plain X-ray
• Useful to identify: 1. Trauma
2. Compression fractures
3. Dislocation
4. Degenerative changes
5. Check spinal curvatures
6. End stages of malignancies
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Plain X-ray
• AP & lateral view of lumbosacral spine
• Not highly sensitive or specific• Not rule out serious illness• Not good at identifying muscles and ligaments
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MRI• Provide more detailed images of soft tissues (disc & Nerve roots)
1. Spinal stenosis2. Disc bulge3. Spinal tumors4. Infections5. Compressive lesions6. Cauda equina
Note : -If red flags are present , MRI should be undertaken even if X-ray is normal.-MRI is preferable to CT scanning when neurological signs and symptoms are present
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CT-scan
• Most of boney spinal pathology1. Trauma 2. Osteomylitis 3. Infection4. Tumors 5. Cases where MRI is contraindicated (e.g. pacemaker or metallic clips)• More radiation exposure
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Radionuclide (bone scan)
• Useful when radiographs of the spine are normal
but the clinical findings are suspected 1. Osteomyelitis
2. Bony neoplasm
3. Occult fracture
• Unlikely to demonstrate bone changes when radiographs and ESR are normal
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Radionuclide (bone scan)
• More sensitive than radiography
in detecting :
1. Metastasis
2. Paget’s disease (metabolic, bone turnover)
3. ankylosing spondylitis (Inflammatory
condition)
4. Trauma
5. Certain tumors (osteiod osteoma= benign)
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Laboratory tests
• Indications:
1. Red flag signs
2. Malignancies or Infections
3. Metabolic causes
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Laboratory tests
• FBC• ESR/CRP• Others( HLA B27 Ag),(Ca2+,PO4,Alkaline
phosphatase)
• HLA B27 is a protein in WBCs– If positive, possible ankylosing spondylitis (AS)– HLA B27 positive without having AS– 95% of AS sufferers are HLA B27 positive
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Laboratory tests
Diagnosis Test’s resultInflammation or malignancy Raised CRP or ESR
Metastatic carcinoma of the prostate
Raised acid phosphatase or prostate specific antigen
Other bone metastases and Paget’s disease
Raised alkaline phosphatase
Myeloma Monoclonal band on serum immunoelectrophoresis and presence of urine light chains
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• How to treat MR.B ??
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Treatment
Symptomatic treatment
• Aims to:1. Relive pain
2. Improve quality of life
3. Treat underlying cause
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Non-pharmacological
• Explanation• Reassurance• Advice on exercise
• Simple analgesics
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Pharmacological
• Regular analgesia and/or non-steroidal anti-inflammatory drugs (NSAIDs) may be required to:
1. Improve mobility
2. Facilitate exercise
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Pharmacological
• Opiates can be used for severe pain (single dose)• Tricyclic antidepressant drugs (analgesics+sleep &
mood)
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Would you advice bed rest?
• Bed rest should not be advised • Returning to normal activities as soon as possible
(reduce chance of chronic pain)
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Complementary and alternative medicine
• Acupuncture• Spinal manipulation• Massage therapy• Physical therapy
• Exercise
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Knee to Chest
Pelvic Tilt
Hip Rolling
Pelvic Lift
Curl Ups
Hip Extension
Lying Prone In Extension
Back Extension
Arm Lifts
Hip Extension
Push Up
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When to refer?
• No significant improvement in symptoms after 4-6 wks of treatment (reassess the treatment plan).
• To avoid misdiagnosis and unnecessary or inappropriate treatments
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Referral to spine specialist
• Cauda equina syndrome• Intractable pain• Serious spinal pathology is suspected• Progressive neurological deficits
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Risk factors
• Prior history of back pain• Heavy lifting• Frequent bending• Twisting and lifting• Repetitive work with exposure to vibration
• Psychosocial issues
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Prevention • Limited number of studies• Overall , effective strategies for preventing initial or
recurrent low back pain are lacking• Education:
1. Instruction on proper lifting technique (not seem to be helpful)
2. Coping with back pain and encourages activity (small benefit)
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Prevention
3. Back belt and lumbar support (not effective in workers)
4. Most effective prevention strategy seems to be physical exercise
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Differential diagnosiscompliant Diagnosis
1- 42 yrs male, alcoholic has abdominal pain radiated to the back.
Referred pain
2- 70 yrs old female known to have osteoporosis has h/o trauma.
fracture
3- 50 yrs male has Fever, back pain unrelieved by bed rest or remaining motionless.
Infection
4- 22 yrs male has Pain unrelieved by remaining motionless and morning stiffness relieved by exercise
AS
5- 54 yrs old female k/c/o breast Cancer on chemotherapy. Spinal ca.
6- Acute onset of urinary retention or fecal incontenence,loss of anal sphincter tone ,saddle anasthesia,global/progressive lower extremity weakness
Cauda equinasyndrome
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References
• Philip D. Sloane, Lisa M. Slatt, Mark H. Ebell, Louis B. Jacques, Mindy A. Smith. Essentials of Family Medicine. Fifth edition
• Robin C. Fraser. Clinical Method .A general practice approach. Third edition
• Davidson’s. principles & practice of medicine. Twentieth edition
• Oxford handbook of general practice. Third edition• Oxford handbook of clinical medicine. Seventh
edition
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