Back Pain (Rheum)

Question 1

Low back pain with paraspinal tenderness + normal neuro exam

Answer 1

Mechanical

• Muscle strain
• Disc degeneration

Question 2

Low back pain w/ radiation below knee, +straight leg raise test, neurologic deficits

Answer 2

Radiculopathy

(Herniated disc)

Question 3

Low back pain w/ pseudoclaudication, relieved by leaning forward

Answer 3

Spinal stenosis

Question 4

Low back pain worse w/ rest, improved with activity, with pain in the SI joints

Answer 4

Inflammatory

(Spondyloarthropathies; PAIR):

• Ankylosing spondylitis
• Psoriatic arthritis
• Reactive arthritis
• Inflammatory Bowel Disease

Question 5

Low back pain, worsens w/ activity, relieved with rest

Answer 5

Lumbar osteoarthritis

Question 6

Low back pain >50yo, worse at night, not relieved with rest

Answer 6

Metastatic cancer

(Spinal mets)

Question 7

Low back pain + IVDU or recent infection, fever, focal spine tenderness

Answer 7

Infectious

• Osteomyelitis
• Discitis

Question 8

Low back pain + midline tenderness

Answer 8

Vertebral fracture

Question 9

Low back pain that increases w/ standing, walking, or lying on back

Answer 9

Vertebral Compression Fracture

(usually 2/2 osteoporosis)

Question 10

Low back pain that is posture-dependent & persistent when standing

Answer 10

Lumbar spinal stenosis

(Neurogenic claudication)

Question 11

Low back pain that is exertional and goes away within ~30 seconds of sitting

Answer 11

Vascular claudication

(PVD)

Question 12

Low back pain relieved by flexion of the spine

Answer 12

Lumbar spinal stenosis

• Relieved w/ sitting & walking uphill (spinal flexion)

Question 13

Evaluation for peripheral vascular disease that presents with vascular claudication

Answer 13

ABI

(Ankle-Brachial Index)

Question 14

Gene and age group of ankylosing spondylitis (AS)

Answer 14

• HLA-B27
• 15-30yo young males

Question 15

Enthesitis (inflammation/tenderness at tendon insertion sites)

Answer 15

Spondyloarthropathies (PAIR):

• Psoriatic arthritis
• Ankylosing spondylitis
• Inflammatory Bowel Disease
• Reactive arthritis

Question 16

Low back pain worse at night, improves with rest

Answer 16

Spinal osteomyelitis

(if worse @ night but not relieved w/ rest, suspect metastatic cancer)

• +fever
• +IVDU or recent infection
• +focal spine tenderness

Question 17

Low back pain worse in the morning, improves with activity, + diarrhea/abd pain

Answer 17

IBD-associated arthritis

(PAIR spondyloarthropathy)

• Psoriatic/Ankylosing/IBD/Reactive

Question 18

Severe back pain + saddle anesthesia (S3-S5) + hyporeflexia + asymmetric motor weakness

Answer 18

Cauda equina syndrome

(LMN only because peripherally located, compared to conus medullaris)

Question 19

Severe back pain + perianal anesthesia + hyperreflexia + BL motor weakness (mild)

Answer 19

Conus medullaris syndrome

(UMN & LMN signs because conus medullaris is part of the spinal cord)

Question 20

Low back pain worse at night, worse in recumbent position, gradually worsening & severe, symmetric LE weakness, decreased/absent rectal sphincter tone

Answer 20

Spinal cord compression (SCC)

• Eemrgency MRI
• IV Glucocorticoids
• Rad-onc & neurosurgery consults
• DDx:
  
  • Spinal injury (MVC)
  • Malignancy (e.g. lung/breast/prostate; myeloma)
  • Infection (e.g. epidural abscess)