Transcript Case Study: Back Pain

Nursing 870
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87 y/o white female with lumbar back pain over
2 weeks. Worse last 4 days to the point of not
being able to walk due to the pain. Slid on to
floor 2 weeks ago. No previous problems
ambulating in the past. PMH scleroderma of
skin(psoriasis), Unsure whether saw PMD or
therapist within the last week.
Meds: Steroid cream
PE: Essentially negative except neuro examine:
able to lift legs off the bed. Toes downgoing.
Reflexes not noted.
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What Other History Components are Missing?
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Injury?
Any red flag associated signs/symptoms?
◦ Cancer
 Fever
 Unexplained weight loss
 Pain duration > 1 month or failure to improve with 1
mo treatment
 Age > 50
 History of cancer
 Bed rest without relief
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Osteomyelitis
◦ History of drug abuse, UTI, or skin infection
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Compression fracture
◦ Age > 50 (some studies > 70)
◦ Corticosteroid use
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Herniated disc
◦ Sciatica
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Cauda Equina syndrome
◦ Bladder or bowel dysfunction
◦ Urinary retention with overflow incontinence
◦ Saddle anesthesia
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Spinal stenosis
◦ Pseudoclaudication
 Pain with walking, relieved by rest
◦ Age > 50
◦ Pain relieved with sitting or spine flexion
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Ankylosing spondylitis
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Age at onset < 40
Pain not relieved in supine position
Morning back stiffness
Duration of pain > 3 mo.
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What diagnostic tests are indicated here?
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Pt admitted without x-rays and labs?
Pt with progressive paresis of lower extremities
and developed a fever that night in the hospital.
MRI the next day demonstrated epidural abscess.
Patient requires immediate surgical intervention.
Epidural Abscess grows MRSA. Pt using steroid
cream on skin for psoriatic rash daily like skin
lotion. It is believed patient made herself
immunosuppressed and probably had a
hematogenous spread of infection from skin to
spine.
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5th most common symptom for all primary
care visits
Estimated that 84% of adults will have back
pain at some point
< 5% of patients with serious pathology
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Risk factors for the onset of back pain include:
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Smoking
Obesity
Older age
Female gender
Physically strenuous work
Sedentary work
Psychologically strenuous work
Low educational attainment
Workers' Compensation insurance
Job dissatisfaction
Psychological factors: somatization disorder, anxiety,
and depression
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Is there evidence of systemic disease?
Is there evidence of neurological
compromise?
Is there social or psychological distress that
might contribute to pain?
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Focused PE Should Include:
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Inspection of back and posture
Range of motion
Palpation of the spine
Straight leg raising (for patients with leg symptoms)
Neurologic assessment (for patients with leg symptoms)
 L4: knee strength and reflexes
 L5: great toe and foot dorsiflexion strength
 S1 : foot plantar flexion and ankle reflexes
◦ Evaluation for malignancy (breast, prostate, lymph node
exam) when persistent pain or history strongly suggests
systemic disease
◦ Peripheral pulses should be evaluated in older patients
with exercise-induced calf pain to rule out vascular
claudication.
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Categorizes patients into risk categories
◦ Non-specific (> 85% of cases)
◦ Associated with radiculopathy or spinal stenosis (610%)
◦ Other causes
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Consider Fibromyalgia
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https://www.accp.com/docs/bookstore/acsap/a15b1_m1sample.pdf
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Not indicated in first 4-6 weeks unless:
(Recommendation 2)
Progressive neurological findings
Constitutional symptoms
History of traumatic onset
History of malignancy
Age ≥50 years
Infectious risk such as injection drug use,
immunosuppression, indwelling urinary catheter,
prolonged steroid use, skin or urinary tract
infection
◦ Osteoporosis
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X-rays
◦ R/O tumor, fracture, infection, instability,
spondyloarthropathy, and spondylolisthesis
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CT
MRI
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MRI preferred (Recommendation 3)
◦ Evaluate persistent low back pain and signs of
symptoms of radiculopathy or spinal stenosis if
they are candidates for surgery or epidural steroids
◦ Most patients symptoms subside or improve within
4 weeks
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Provide education about expected course
Advise patients to remain active
Provide information about self-care
◦ Heat
◦ No evidence to support ice
◦ Medium to firm mattress support
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Use of exercise
Acupuncture
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Acetaminophen
◦ No good evidence for usefulness for acute pain
◦ Useful in osteoarthritis
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NSAIDs ( with or without PPI)
◦ Nonselectives appear to more effective
◦ Provide better relief
◦ Good evidence for short-term effectiveness
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Opioid analgesics or Tramadol
◦ For severe disabling pain, short term
◦ For long-term use, chronic pain
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Skeletal Muscle relaxants
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Tizanidine (Zanaflex): antispastic
Others without good evidence
Benzodiazapenes without good evidence
Use associate with higher number adverse events
Antidepressants (chronic pain)
◦ Tricyclics for chronic pain
◦ Good evidence
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Herbals
◦ Capsicum, devil’s claw, willow bark
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Systemic corticosteroids not recommended
◦ No good evidence
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Spinal manipulation
PT (chronic or subacute)
Exercise
◦ May start after 2-6 weeks; time unclear
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Massage therapy
Yoga
Cognitive-behavior therapy
Progressive relaxation
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Tizanidine with acetaminophen or NSAID
◦ Greater short term pain relief than acetaminophen
or NSAID alone
◦ Higher risk adverse events
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Neurosurgeon or Ortho surgeon specializing in
backs
◦ Cauda equina syndrome – typical features are bowel and
bladder dysfunction (urinary retention), saddle
anesthesia, and bilateral leg weakness and numbness.
The cauda equina syndrome is a surgical emergency.
◦ Suspected spinal cord compression – this may present as
acute neurologic deficits in a patient with cancer and
risk of spinal metastases, and requires emergent
evaluation for surgical decompression or radiation
therapy, with specific management determined by the
underlying pathology.
◦ Progressive or severe neurologic deficit
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Patients may also be referred to a neurologist
or physiatrist if any of the following are
present:
◦ Neuromotor deficit that persists after four to six
weeks of conservative therapy
◦ Persistent sciatica, sensory deficit, or reflex loss
after four to six weeks in a patient with positive
straight leg raising sign, consistent clinical findings,
and favorable psychosocial circumstances (eg,
realistic expectations and absence of depression,
substance abuse or excessive somatization).
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Chou, R. & Huffman, L. H. (2007). Medications for acute and chronic
low back pain: A review of therEvidence for an American Pain
Society/American College of Physicians Clinical Practice Guideline .
Annals of Internal Medicine, 147, 505-514.
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Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, T., Shekelle, P., &
Owens, D. (2007). Diagnosis and treatment of low back pain: A joint
guideline from the American College of Physicians and The American
Pain Society. The American College of Physicians, 147, 478-491.