2. HYHO: SPE 3-3

Question 1

Describe how often patients come into clinic with non-specific LBP and what is often the course?

Answer 1

>85% of pts that go to clinic have LBP and most improve in few weeks

Question 2

Because it is not always possible to determine cause and to rule out SERIOUS cases of LBP, ______ is KEY in figuring out cause of LBP

Answer 2

HISTORY; ask about other symptoms!

Question 3

When taking history for LBP, it is important to ask about _____.

Answer 3

Constitutional symptoms: unintentional WL/fever/sweats, hx of cancer, neurologic sx, injection drugs.

Question 4

Factors that suggest LBP is due to a systemic disease (5), < 1% have serious systemic etiology

Answer 4

1. Hx of cancer
2. > 50 YO
3. Unexplained WL
4. Pain > 1 month; worse at night
5. Not respond to previous therapies

Question 5

Acute, subacute and chronic LBP

Answer 5

1. Acute: < 4 weeks
2. Subacute: 4-12 weeks
3. Chronic: > 12 weeks

Question 6

_______ is most commonly caused by herniation of intervertebral disc.

Answer 6

Spinal cord or cauda aquina compression

Question 7

Cord Compression

• _____ = usually FIRST symptom
• _____________ = found in majority of patients when diagnosed
• ___________ = late symptoms

Answer 7

• Pain
• Motor weakness & sensory findings
• Bowel or bladder dysfunction

Question 8

_________ = strongest risk factor for back pain from bone metastasis

Answer 8

History of cancer

Question 9

Spinal epidural abscess

• __________\_ = initial symptoms
• Change overtime

Answer 9

• Nonspecific symptoms (fever and malaise)
• Localized BP => radicular pain => neurologic deficits

Question 10

BP that gradually increases over week => months that MAY/MAY NOT present w fever

Answer 10

Vertebral osteomyelitis

Question 11

Other etiologies outside of spine that cause LBP

Answer 11

1. Pancreatitis
2. Nephrolithiasis
3. Pyelonephritis
4. AAA
5. Herpes Zoster

Question 12

Name the lumbar nerve root

Answer 12

• Blue => L4
• Orange => L5
• Green => S1

Question 13

L4

• Motor weakess:
• To screen:
• Reflex:

Answer 13

L4

• Motor weakess: extension of quads
• To screen: squat and rise
• Reflex: knee jerk will be diminished

Question 14

L5

• Motor weakess:
• To screen:
• Reflex:

Answer 14

L5

• Motor weakess: dorsiflex big toe and foot
• To screen: walk on heels
• Reflex: N/A

Question 15

S1

Motor weakess:

To screen:

Reflex:

Answer 15

S1

Motor weakess: Plantarflex big toe and foot

To screen: walk on toes

Reflex: Diminshed ankle jerk reflex

Question 16

OSE Sympathetics

1. Head/neck (upper ESO)
2. Heart
3. Lungs
4. UGI (lower ESO)
5. SI/ascending colon
6. Ascending and transverse colon
7. Descending and sigmoid colon/rectum
8. Adrenal glands
9. GU tract + bladder
10. Ureter (upper/lower)
11. Extremeties (upper/lower)

Answer 16

1. Head/neck (upper ESO) = T1-5
2. Heart = T1- 6
3. Lungs = T1 - 7
4. UGI (lower ESO = T5-10
5. SI/ascending colon= T9 - 11
6. Ascending and transverse colon= = T10 - L2
7. Descending and sigmoid colon/rectum = T12- L2
8. Adrenal glands = T5 - 10
9. GU tract + bladder = T10 - L2
10. Ureter (upper/lower) = T10-11/ T12- L2
11. Extremeties (upper/lower) = T2-7/ T11 - 12

Question 17

LBP _____ = no imaging

Answer 17

less than 4 weeks (acute LBP) bc most will improve rapidly

Question 18

Who should get imaging for LBP?

Answer 18

1. Severe or progressive neurologic deficits
2. Serious underlying conditions are suspected based on hx and PE

Question 19

________= emergent MRI and referral to specialist

Answer 19

1. Spinal cord/cauda equina compression (new urinary retention/incontinence, new fecal incontinence, saddle anesthesia)
2. Progressive and/or severe neurologic deficits (Significant/progressive motor deficits not localized to 1 nerve root)

Question 20

Imaging?

Radiculopathy due to 1 nerve root or with stable sx due to spinal stenosis

Answer 20

No, unless

• High risk metastic cancer => plain XR + EST or CRP
• Moderate - high risk of infection => MRI

Question 21

What are “red flag” sx for LPB?

Answer 21

Sx that may ID pts at risk for more dangerous cause of back pain and should get earlier imaging

Question 22

Red flag sx for LBP

Answer 22

1. [Older age, prolong use of corticosteroids, severe trauma and contusion/abrasion] => increase risk of vertebral fracture
2. Hx of cancer => increase risk of spinal cancer

Question 23

Imaging for suspected renoithiasis

Answer 23

• CT of abdomen and pelvis W/O contrast using low-radiation.
• If no CT => US of kidney & bladder + abdominopelvic XR

Question 24

What to do in PE for LBP? (4)

Answer 24

1. Abdominal exam
2. Structural exam
3. Reflexes
4. Strength and sensation

Question 25

Sx of **cauda equina syndrome**

Answer 25

1. **Urinary retention** 2. **Saddle anesthesia** 3. **Bilateral leg weakness** 4. **Bilateral sciatica**

Question 26

Sx of **infection**

Answer 26

1. **Fever** 2. **Recent skin/UTI** 3. **Immunosupression** 4. **Use injection drugs**

Question 27

Sx of **cancer**

Answer 27

1. **Hx of cancer** 2. **Unexplained WL** 3. **\> 50** 4. **Lasts \> 1 month**

Question 28

Sx of **compression fracture**

Answer 28

1. **\> 70 YO** 2. **F** 3. **Corticosteroid use** 4. **Hx of osteoporosis** 5. **Trauma**

Question 29

Sx of **lumbar radiculopathy**

Answer 29

1. **Sciatica** 2. **Abnormal neurologic exam**

Question 30

Tx of **acute LBP**

Answer 30

1. **Nonpharmacologic therapy**: superficial heat and patient education 1. Massage, acupuncture, spinal manipulation 2. **If not responsive or prefer meds:** short-term (2-4 weeks) NSAIDS/ acetominophen if CI. 1. Refractory pain =\> nonbenzo muscle relaxand

Question 31

For **acute LBP,** is bed rest and activity recommended?

Answer 31

* No bed rest * Keep activity to a minmum; do **not** refer for XRCISE or PT unless have RF for chronic

Question 32

What should be included in patient education in LBP?

Answer 32

1. Cause 2. Prognosis 3. Minimal value of diagnostic testing 4. Recommendations for activity and work 5. When to contact doc

Question 33

If **not** adequate relief or CI to other drugs, give = \_\_\_\_\_\_\_\_\_\_

Answer 33

* **Opoids** (only for 3-7 days) and **tramadolol** (no longer than 2 weeks)

Question 34

When should pts with LPB be reassessed?

Answer 34

No improvement **after 4 weeks** of pharmocotherapy

Question 35

Predictors o**f chronic LBP**? (5)

Answer 35

1. **Cannot cope with pain** 2. **Functional impairment** 3. **Poor health** 4. **Psychiatric problem** 5. **Nonorganic signs**