Download Acute Low Back Pain

Common Problem of
the Musculoskeletal
y
- II
System
Limb Pain,
Lower back pain
本講義表格資料取自
本講義表格資料取自Dains,
J.E., Baumann, L.C., & Scheibel, P. (2007). Advanced assessment and clinical diagnosis in primary
care. (3rd ed). St. Louis: Mosby.
1
圖片取自Seidel
圖片取自
Seidel HM, Ball JW, Dains JE, Benedict GW. (1999). Mosby’s guide to physical examination.
examination. St. Louis, MO: Mosby.
Acute Low Back Pain
2
Acute lower back pain
„ Actively intolerance producing lower back or
back-related
b
k l t d leg
l symptoms
t
off less
l
th
than 3
months duration
„ Most common cause
„ Musculoskeletal
injuries
„ Age-related degenerative process
„ 90% resolved within 4 weeks without serious
sequelae
3
AHRQ’s causes of ALBP
„ Potentially serious conditions
„
Spinal fracture
fracture, tumor or infection
infection, cauda equina syndrom
„ Nerve root compression
„
Sciatic or leg pain and numbness of the lateral thigh
thigh, leg
leg,
and foot (nerve root compression)
„ Nonspecific
p
back p
problems
„
Musculoskeletal strain, dickogenic pain, bony deformity
2ndary to inflammatory disease
„ Nonspinal causes secondary to abdominal involvement
„ Psychological causes
(Agency for Healthcare Research and Quality)
4
Testing
g for lumber nerve root compromise
p
5
DIFFERENTIAL DIAGNOSIS OF Common Causes of Acute Low Back Pain
CONDITION
HISTORY
PHYSICAL FINDINGS
DIAGNOSTIC STUDIES
Potentially Seriou Causes
Spinal fracture
Trauma to spine or back; Palpable tenderness
pain is felt near site of
p
over site of fracture
injury
Considered an
emergency;
g
y; immobilize
patient and transport for
radiographs
Tumor
History of cancer;
progressive pain is
unremitting; occurs at
night and at rest
Weight loss, fever,
tenderness near
tumor
ESR; bone scan
Osteoblastoma
Neck or back pain not
relieved by aspirin;
occurs in older
adolescents and young
adults
Localized tenderness; Plain film shows an
may have scoliosis
expansive osteolytic
with muscle pain
lesion surrounded by
thin peripheral rim of
bone; bone scan; CT
scan
Osteoid
osteoma
Occurs primarily in
adolescents;; rare in
patients over age 40;
well localized pain that
may be more severe at
night and relieved by
aspirin or other
prostaglandin inhibitors
Painful, welllocalized scoliosis
may be present
Bone scan
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DIFFERENTIAL DIAGNOSIS OF Common Causes of Acute Low Back Pain
CONDITION
HISTORY
PHYSICAL FINDINGS
DIAGNOSTIC STUDIES
Potentially Seriou Causes
Infection
( t b l
(vertebral
osteomyelitis)
History of infection,
i
invasive
i procedure;
d
continuous, dull back
pain; chronic back pain
Acute onset presents
ith fever,
f
diaphoresis;
di h
i
with
tenderness over affected
disk; positive
SLR(straight leg raising)
ESR; blood culture;
b
bone
bi
biopsy; CT
scan; MRI
Diskitis
Pain aggravated by
movement; more
common in children
Tenderness overaffected disk
ESR
Cauda equina
syndrome
Constant pain in a
saddle distribution;
urinary retention, fecal
incontinence
incontinence,
radiculopathy
Positive SLR, abnormal
DTRs, motor weakness
Surgical emergency
Paravertebral
tenderness and spasm;
positive SLR; sitting
。
knee extension < 60
produce radicular pain
below the knee, sensory
findings
EMG if chronic
Sciatica Problems
Sciatica
Acute back pain with
radiculopathy; history of
strain or trauma, relief
with sitting
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DIFFERENTIAL DIAGNOSIS OF Common Causes of Acute Low Back Pain－cont’d
CONDITION
HISTORY
PHYSICAL FINDINGS
DIAGNOSTIC STUDIES
Nonspecific Back Problems
Musculoskeletal
strain
Pain in back, buttocks; history
of new activity or exertion;
relief of pain with sitting
Paravertebral tenderness,
scoliosis, or loss of lumbar
lordosis; no neurological signs
None
Spondylolisthesis
(脊椎炎)
Young person in a sport that
demands rapid movement
between hyperflexion and
hyperextension or requires
excess loading in
hyperextension
No neurological signs; pain
localized to low back, just
below level of iliac crest; tight
hamstrings
Lumbar spine
radiographs
Ankylosing (關節
粘連)spondylitis
Persons under age 40:
insidious onset; progressive
morning back pain relieved
with exercise
Painful sacroiliac joints,
reduced spine mobility; may
have uveitis
ESR; spinal
radiographs
Spinal stenosis
Pain worse throughout day;
aggravated by standing,
standing
relieved by rest;
pseudoclaudication
Signs of osteoarthritis of joints; Spinal radiographs
may have neurological signs
Scheuermann’s
disease
Affects mostly adolescent
males; mild to moderately
severe pain, worse at end of
day, relieved by rest
Normal examination; may
show an exaggerated thoracic
kyphosis that is fixed in
attempted hyperextension
Thoracic spine
radiographs
Osteoporosis
Chronic, poorly localized back
pain; postmenopausal; slight
build; history of inactivity or
endocrine disorder
Palpable tenderness over
area of compression fracture;
kyphosis or lordosis; loss of
height
Bone densiometry;
spinal radiograph to
assess fracture
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DIFFERENTIAL DIAGNOSIS OF Common Causes of Acute Low Back Pain－cont’d
CONDITION
HISTORY
PHYSICAL FINDINGS
DIAGNOSTIC
STUDIES
Nonspinal Causes
Aortic aneurysm
Severe, acute-onset pain not
related to activity or movement;
increase risk in persons over
age 30; pallor, diaphoresis,
anxiety, confusion
Intact aneurysm will be a visible
pulsatile midline upper quadrant
abdominal mass; in a dissected
aneurysm, upper extremity pulse
and pulse pressures are
asymmetrical; posterior thoracic
pain may be felt
Emergency surgical
referral
Gallstones
Increased incidence with age;
steady, intense pain in RUQ
with radiation to right scapula
or shoulder; belching, bloating,
fatty food intolerance
Normal physical examination or
positive Murphy’s sign on
palpation of abdomen
Surgical referral
Pyelonephritis
Ill-appearing; sweating,
nausea, back
b k or fl
flank
k pain,
i
headache
Fever: cloudy, malodorous urine;
CVA ttenderness
d
on percussion
i
Urinalysis; urine
culture
lt
Pleuritis
History of recent URI; pleuritic
pain
Normal examination or crackles
and bronchial breath sounds
PPD; chest
radiograph
Exaggerated or inconsistent
reactions to testing; normal
examination
None
Psychological back pain
Psychological
back pain
History of psychosocial
stressors depression
stressors,
depression,
exaggerated expressions of
pain
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Focused History
„ Is This a Potentially Serious Cause of ALBP？
Do you have a fever？
Have you experienced any trauma to the spine or back？
Do you have any other health problems ? Have you been treated
f cancer？
for
？
What is your age？
Have yyou had loss of control of yyour bowels or bladder？
Are you taking any medications？
„ F
Fever indicating
i di i iinflammatory
fl
condition
di i
„ Injury to the back usually cause contusions and abrasions
but also can cause spinal fracture
„ Loss of urinary or stool continence indicates cauda equina
or S1-S2 nerve compromise
p
secondary
y to herniated disk.
10
Focused History
„ What Does the Location of Pain Tell Me？
Wh
Where
does
d
it h
hurt?
t?
„ Siatic pain is a sharp
sharp, burning pain that radiates down the posterior
and lateral leg to the foot or ankle.
„ Back pain with neck stiffness can indicate cervical osteomyelitis.
„ Rheumatoid arthritis produced pain in the upper back and neck
„ Localized pain is seen with spondylolysis and tumors.
„ Flank pain in adults may indicate a kidney infection.
„ Pain of gallbladder disease radiates to the subcapular area.
„ Compression fracture of vetebrae associated with osteoporosis or
malignancy may produce pain over midthoracic area
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Focused History
„ What Does the Pattern of Pain Tell Me？
When did the pain start？
How long have you had this pain？
What does the pain feel like？
Does it interfere
f
with sleep？
Have you had this pain before？
„
The onset of ALBP is sudden, and more than half of patients with this
symptom do not associate it with a specific precipitating event or injury.
„
Subacute back pain is 6~12 week duration.
„
Chronic back pain is pain more than 3 months duration
„
Night pain is a worrisome symptom that often signals a serious such as
tumor, infection, or inflammation.
„
Morning
M
i stiffness
tiff
that
th t improves
i
as the
th day
d progresses suggests
t ankylosing
k l i
spondylitis.
12
Focused History
„ What Does the Pain in Relation to Activity Tell Me？
What makes the p
pain worse？
？
What makes the pain better？
„ Pain
P i that
th t is
i aggravated
t d by
b activity
ti it andd alleviates
ll i t by
b restt is
i
„
„
„
„
usually muscuoskeletal in origin.
Spinal stenosis is associated with increased pain with standing,
standing
sneezing, or coughing, and is relieved on flexion of the spine..
Pain experienced in the lumber area occurring after strenuous
sporting activities is usually the result of trauma to muscles and
tendons, causing contusion and sprain.
Suspect spondylolisthesis
spondylolisthesis, or forward slippage of one vetebra
over another, if the onset of pain is during hyperextension.
Back
ac pa
pain not
o associated
assoc a ed with
w any
a y activity
ac v y and
a d not
o relieved
e eved by
rest may indicate tumor.
13
Focused History
„ What Does Rediation of Pain Tell Me？
Does th
D
the pain
i ttravel？
l？
Show me Where the pain travel？
„ Pain from the upper lumber spine usually radiates to the anterior
aspect of the thigh and leg.
„ Pain from the lower lumber spine usually radiates to the gluteal region,
posterior thigh, and calves.
„ Pain
P i ffrom visceral
i
l di
disease iis usually
ll ffelt
lt within
ithi th
the abdomen
bd
and
d flflank.
k
Gallbladder pain radiates around the trunk to right scapula.
„ Person with spondylolysis complain of hamstring tightness and buttack
discomfort as well as low back pain.
„ Siatic pain: sharp, burning radiates down to the lateral or posterior
aspect of the leg to the lateral ankle or foot
14
Focused History
„ Are There Signs of Neurological Damage？
Have you b
H
been stumbling？
t bli ？
Have you noticed any change in your balance or
coordination？
Does the child frequently stumble or fall？
Do yyou have numbness or tingling
g g in yyour extremities？
？
„
Is There a Family History of Back Pain？
Does anyone
y
in yyour familyy have scoliosis or a crooked
spine？
„
Could This Pain Be Caused by a Systemic Disease？:
Have you been ill？ eg, PID, URI,
15
Focused PE
„ Observe the Patient,s General
„
„
„
„
„
„
„
Appearance
Observe Gait
Assess Vital Sign
Examine Skin
Examine Eyes, Ears, Nose, and
mouth
Inspect the Back and
Extremities
Percuss and Palpate Back and
Spine
Perform Range of Motion of the
Spine
„ Perform Straight Leg Raising
„ Check Hip Mobility
„ Examine Feet
„ Evaluate Muscle Strength
g
„ Measure Muscle Circumference
„ Test Sensory function
„ Assess Deep Tendon Reflexes
„ Palpate the Abdomen
„ Check Rectal Sphincter Tone
16
Lab and diagnostic studies
„ Plain Radiographs
„ Electromyography
„ Standing Anteroposterior
„ Diagnostic Imaging
and Lateral Views of the
Spine
„ Oblique and Flexion Views
of the Spine
„ Spine Radiograph
„ Bone Scan
„ Urinalysis
„ Erythrocyte Sedimentation
Rate
„ Complete
C
l t Bl
Blood
dC
Cellll
Count
17
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