Kai1111
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Useful Low Back Pain Review
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05.01.08 (4 months ago)
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Useful Low Back Pain Review (from:
Low back pain may be a symptom of a serious condition
A thorough history and physical exam are key to diagnosis and proper management. Is your patient's low back pain a symptom of . . .
• Ankylosing spondylitis? This condition occurs in young men with gradual onset of back stiffness, especially in the morning. Active or old iridocyclitis (iridic adhesions or dark spots in the anterior chamber), arthritis, and a history of inflammatory bowel disease are clues. Schober's maneuver, revealing limited flexion, is sensitive but not specific.
• Aortic dissection? Key findings include acute onset; moving, tearing back pain; a restless, shocky patient; asymmetric femoral pulses; abdominal pulsation; abdominal bruit.
• Cauda equina syndrome? Findings include urinary retention or overflow incontinence, saddle anesthesia, bilateral leg weakness or numbness, and anal sphincter laxity. Ankle jerks are decreased but knee jerks are increased (due to unopposed quadriceps). Commonly caused by a herniated disk.
• Compression fracture? Related to osteoporosis, this occurs mostly in older patients and those taking steroids. The usual history is sudden pain caused by flexion stress. Pain is localized over the vertebrae or around the trunk, and there is often tenderness to palpation over the spinous processes. The upper lumbar or lower thoracic vertebrae are most commonly affected. Consider metastatic cancer, myeloma, and hyperparathyroidism as alternative causes.
• Epidural abscess? The characteristic presentation is radicular pain or progressive muscular weakness in a febrile patient who has localized back pain and tenderness. Pain increases upon recumbency, sudden movements, or Valsalva's maneuver. Lhermitte's sign, a transient electric-like sensation shooting down the back when the patient flexes the head, is often present. Early signs of impending paraplegia include extensor plantar reflex (toes pointing downward), leg weakness, and urinary retention.
• Lumbar disk herniation?
• Metastatic cancer? The onset of back pain is insidious, is not relieved by lying down, often occurs at night, and may be described as "boring" or "expansive." A history of cancer and unexplained weight loss are specific findings. Myeloma and prostate, breast, lung, and colon cancers are common sources.
• Musculoligamentous strain?
• Osteoarthritis? Recognized as pain and stiffness with flexion and rotation in a patient who has evidence elsewhere of osteoarthritis (eg, Heberden's and Bouchard's nodes). Hypertrophied facets, osteophytes, and spondylolisthesis may cause root compression.
• Pancreatic cancer? This presents insidiously with relentless dull upper-lumbar backache with abdominal pain. Weight loss and depression are prominent.
• Pyelonephritis? Renal infection presents with fever, prominent nausea, chills, urinary frequency, and costovertebral angle tenderness.
• Sacroiliitis? The sacroiliac joints, marked by sacral dimples, are deeply tender.
• Scoliosis? Functional scoliosis disappears while structural scoliosis increases with flexion.
• Secondary gain? Clues are inconsistent with symptoms or physical findings, anger, focus on attribution of symptoms with relatively little concern about what can be done to cure the problem, and impending litigation.
• Spinal stenosis? This occurs most often in the elderly as chronic low back pain with evidence elsewhere (hands or knees) of osteoarthritis. Pain worsens upon standing without walking and is relieved by sitting or flexing the spine and hips. Pain may radiate into the legs and is often bilateral and poorly localized.
• Spondylolisthesis? This may be asymptomatic. But when symptoms occur, flexion and extension of the low back are painful, and motion is limited. A palpable shelf that increases with flexion is present at the level of the defect.
• Transverse process fracture? The origin is violent muscular contraction of the psoas. Exquisite tenderness lateral to the spinous process is present. May be associated with retroperitoneal bleeding leading to hypovolemic shock.
• Vertebral osteomyelitis? Findings include low-grade fever, dull, continuous progressive back pain, and tenderness to percussion over the spine.
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