Lower back pain: Difference between revisions
No edit summary |
No edit summary |
||
| Line 1: | Line 1: | ||
== | ==Background== | ||
*Pain lasting >6wk is risk factor for more serious disease | |||
==Clinical Features== | |||
*Musculoskeletal pain | |||
**Located primarily in the back w/ possible radiation into the buttock/thighs | |||
*Sciatica | |||
**Refers to radicular back pain in the distribution of a lumbar or sacral nerve root | |||
**Often accompanied by sensory or motor deficits | |||
**Occurs in only 1% of pts w/ back pain | |||
**95% of herniated disks occur at the L4-L5 or L5-S1 disk spaces | |||
== Work-Up == | == Work-Up == | ||
#Pregnancy test | #Pregnancy test | ||
#Straight leg raise testing | #Straight leg raise testing | ||
##True sciatic tension should elicit pain before | ##True sciatic tension should elicit pain before hamstrings are stretched enough to move the plevis | ||
#X-rays* (if have red flag) | #X-rays* (if have red flag) | ||
##Adults: AP + lateral of lumbar spine | ##Adults: AP + lateral of lumbar spine | ||
| Line 137: | Line 23: | ||
##Rule-out AAA | ##Rule-out AAA | ||
=== CT/MRI | === CT/MRI Indications === | ||
#Suspect | #Suspect disk disease w/ severe motor impairment | ||
#Suspect abcess or mets w/ neuro | #Suspect abcess or mets w/ neuro involvement | ||
#Cauda equina syndrome | #Cauda equina syndrome | ||
#Elevated ESR | #Elevated ESR | ||
== Red Flags == | == Red Flags == | ||
*See [[Back Pain (Red Flags)]] | *See [[Back Pain (Red Flags)]] | ||
== DDX == | == DDX == | ||
*AAA | *AAA | ||
| Line 184: | Line 71: | ||
== Cord Compression == | == Cord Compression == | ||
*L4 | |||
**pain frnt leg, weak knee ext., sens. loss knee/medial foot, lose knee jerk. | |||
*L5 | |||
**pain side leg, wk dorsiflex, sens. loss lat lo leg & web big toe, reflex intact. | |||
*S1 | |||
**pain back leg, weak plantarflex, sens. loss calf/lat foot, ankle jerk gone. | |||
-Straight leg raise most sens., crossed most specific. | -Straight leg raise most sens., crossed most specific. | ||
| Line 199: | Line 86: | ||
-Stenosis: back pain w/ walking, usually old person radiation to legs: Pseudo claudication. Usu. will curl after walking to get relief. | -Stenosis: back pain w/ walking, usually old person radiation to legs: Pseudo claudication. Usu. will curl after walking to get relief. | ||
== Treatment | == Treatment == | ||
*Mild to mod: | |||
Mild to mod: | **NSAIDs | ||
*Mod to Severe | |||
**Non-narcotic(toradol/norflex), then 2-10 of MSO4 PRN | |||
**OPIOD (vicodin or percocet) & nonsteroidal for 2-3 dy, then NSAID alone. | |||
Mod to Severe | |||
-#1 NSAIDs: ibuprofen, naprosyn; #2 Valium first choice for spasm as muscle relaxant. #3 Narcotics w/ oxycodone (percocet) 10-15 tabs. (don't use flexoril) | -#1 NSAIDs: ibuprofen, naprosyn; #2 Valium first choice for spasm as muscle relaxant. #3 Narcotics w/ oxycodone (percocet) 10-15 tabs. (don't use flexoril) | ||
| Line 218: | Line 100: | ||
== See Also == | == See Also == | ||
*[[Back Pain (Red Flags)]] | |||
[[Back Pain (Red Flags)]] | |||
== Source == | == Source == | ||
Revision as of 05:02, 19 February 2012
Background
- Pain lasting >6wk is risk factor for more serious disease
Clinical Features
- Musculoskeletal pain
- Located primarily in the back w/ possible radiation into the buttock/thighs
- Sciatica
- Refers to radicular back pain in the distribution of a lumbar or sacral nerve root
- Often accompanied by sensory or motor deficits
- Occurs in only 1% of pts w/ back pain
- 95% of herniated disks occur at the L4-L5 or L5-S1 disk spaces
Work-Up
- Pregnancy test
- Straight leg raise testing
- True sciatic tension should elicit pain before hamstrings are stretched enough to move the plevis
- X-rays* (if have red flag)
- Adults: AP + lateral of lumbar spine
- Children: add oblique views (to evaluate for spondylolisthesis)
- Labs
- CBC/ESR/Chem 7/UA (if >50 yo)
- US
- Rule-out AAA
CT/MRI Indications
- Suspect disk disease w/ severe motor impairment
- Suspect abcess or mets w/ neuro involvement
- Cauda equina syndrome
- Elevated ESR
Red Flags
DDX
- AAA
- Cauda equina syndrome
- Epidural abcess/hematoma
- Spinal fracture with cord/nerve impingement
- Back pain with neurologic def
- Intervetebral disk herniation
- Cancer
- Meningitis
- Sciatica
- Spinal fracture
- Spinal stenosis
- Transverse myelitis
- Vertebral osteo
- Acute ligamentous injury
- Acute muscle strain
- Ankylosing spondylitis
- Degeverative joint disease
- Intervetebral disk disase
- Pathologic fracture
- Seropositive arthritis
- Spondylolithesis
- Cholecystitis
- Esophageal disease
- Pleural effusion
- Pancreatic disease
- Ulcer perforation
- Retrocecal appendicitis
- Large bowel obstruction
- Renal disease
- Pelvic disease
- PID
- Nephrolithiasis
- PNA
- PE
- Pyelonephritis
- Retroperitoneal hemorrhage/mass
Cord Compression
- L4
- pain frnt leg, weak knee ext., sens. loss knee/medial foot, lose knee jerk.
- L5
- pain side leg, wk dorsiflex, sens. loss lat lo leg & web big toe, reflex intact.
- S1
- pain back leg, weak plantarflex, sens. loss calf/lat foot, ankle jerk gone.
-Straight leg raise most sens., crossed most specific.
-Hypertrophic spur formation behind vert. is most likely non-disc cause of + SLR.
-Sciatica: impinged or irritated nerve. radicular distr., sharp, NO paresthesias/pain distal to knee/neuro impairment.
-Stenosis: back pain w/ walking, usually old person radiation to legs: Pseudo claudication. Usu. will curl after walking to get relief.
Treatment
- Mild to mod:
- NSAIDs
- Mod to Severe
- Non-narcotic(toradol/norflex), then 2-10 of MSO4 PRN
- OPIOD (vicodin or percocet) & nonsteroidal for 2-3 dy, then NSAID alone.
-#1 NSAIDs: ibuprofen, naprosyn; #2 Valium first choice for spasm as muscle relaxant. #3 Narcotics w/ oxycodone (percocet) 10-15 tabs. (don't use flexoril)
-Bedrest 2-3 days
-Referral
See Also
Source
1/26/06 DONALDSON (adapted from Rosen, Lampe, Hock)