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Nursing 870 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. What Other History Components are Missing? 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 Osteomyelitis ◦ History of drug abuse, UTI, or skin infection Compression fracture ◦ Age > 50 (some studies > 70) ◦ Corticosteroid use Herniated disc ◦ Sciatica Cauda Equina syndrome ◦ Bladder or bowel dysfunction ◦ Urinary retention with overflow incontinence ◦ Saddle anesthesia Spinal stenosis ◦ Pseudoclaudication Pain with walking, relieved by rest ◦ Age > 50 ◦ Pain relieved with sitting or spine flexion Ankylosing spondylitis ◦ ◦ ◦ ◦ Age at onset < 40 Pain not relieved in supine position Morning back stiffness Duration of pain > 3 mo. What diagnostic tests are indicated here? 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. 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 Risk factors for the onset of back pain include: ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ 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 Is there evidence of systemic disease? Is there evidence of neurological compromise? Is there social or psychological distress that might contribute to pain? Focused PE Should Include: ◦ ◦ ◦ ◦ ◦ 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. Categorizes patients into risk categories ◦ Non-specific (> 85% of cases) ◦ Associated with radiculopathy or spinal stenosis (610%) ◦ Other causes Consider Fibromyalgia https://www.accp.com/docs/bookstore/acsap/a15b1_m1sample.pdf 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 ◦ ◦ ◦ ◦ ◦ ◦ X-rays ◦ R/O tumor, fracture, infection, instability, spondyloarthropathy, and spondylolisthesis CT MRI 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 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 Use of exercise Acupuncture Acetaminophen ◦ No good evidence for usefulness for acute pain ◦ Useful in osteoarthritis NSAIDs ( with or without PPI) ◦ Nonselectives appear to more effective ◦ Provide better relief ◦ Good evidence for short-term effectiveness Opioid analgesics or Tramadol ◦ For severe disabling pain, short term ◦ For long-term use, chronic pain Skeletal Muscle relaxants ◦ ◦ ◦ ◦ 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 Herbals ◦ Capsicum, devil’s claw, willow bark Systemic corticosteroids not recommended ◦ No good evidence Spinal manipulation PT (chronic or subacute) Exercise ◦ May start after 2-6 weeks; time unclear Massage therapy Yoga Cognitive-behavior therapy Progressive relaxation Tizanidine with acetaminophen or NSAID ◦ Greater short term pain relief than acetaminophen or NSAID alone ◦ Higher risk adverse events 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 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). 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. 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.