Unlock Your Glutes
Ddx of back pain
• Musculoskeletal strain (experienced by up to 80% of the population at some time) osteoarthritis, vertebral compression fracture, ankylosing spondylitis
• Disk herniation syndromes (see below)
• Metastatic: lung, breast, prostate, multiple myeloma, lymphoma
• Infectious: vertebral osteomyelitis or epidural abscess (see ID section)
• Visceral disease with referred pain
PUD. cholelithiasis pancreatitis, pancreatic cancer pyelonephritis, nephrolithiasis uterine or ovarian cancer, salpingitis leaking aortic aneurysm
Initial evaluation
• History: location, radiation, neurologic symptoms, infection, malignancy
• General physical examination: local tenderness. ROM. signs of infection or malignancy.
Spurling sign (cervical radicular pain w neck extension & lateral rotation toward affected side) Straight leg raise (© radicular pain at <60°). ipsilateral: 95% Se. 40% Sp: crossed (contralateral): 25% Se. 90% Sp
• Neurologic examination: full motor (including sphincter tone), sensory (including perineal region), and reflexes including anal (S4) and cremasteric (L2)
• Laboratory (depending on suspicions): CBC. ESR. Ca. PO.».
• Neuroimaging (depending on suspicions): x-rays. CT or CT myelography. MRI, bone scan
• EMG NCS may be useful to distinguish root plexopathies from peripheral neuropathies
• Back pain aggravated by activity (esp. bending, straining, and coughing), relieved by resting on unaffected side with affected leg in flexed posture
• "Sciatica" = aching pain that radiates from the buttocks down the lateral aspect of the leg, often to the knee or lateral calf : numbness and paresthesias radiating to lateral foot
Cervical and Lumbar Disk Herniation Patterns | |||||
Disc |
Root |
Pain / Paresthesias |
Sensory loss |
Motor loss |
Reflex loss |
C4-C5 |
C5 |
Neck, shoulder upper arm |
Shoulder |
Deltoid, biceps, infraspinatus |
Biceps |
C5-C6 |
C6 |
Neck, shoulder, lat. arm. radial forearm, thumb & index finger |
Lat- arm. radial forearm, thumb & index finger |
Biceps, brachioradialis |
Biceps, brachioradialis. supinator |
C6-C7 |
C7 |
Neck, lat arm, ring & index fingers |
Radial forearm, index & middle fingers |
Triceps, extensor carpi ulnaris |
Triceps, supinator |
C7-T1 |
C8 |
Ulnar forearm |
Ulnar half of ring |
Intrinsic hand |
Finger |
and hand |
finger, little finger |
muscles, wrist extensors, flexor dig profundus |
flexion | ||
L3-L4 |
L4 |
Anterior thigh. Inner shin |
Anieromedial thigh and shin, inner foot |
Quadriceps |
Patella |
L4-L5 |
LS |
Lat thigh and calf, dorsum of foot, great toe |
Lat. calf and great toe |
Extensor halllcus longus, * foot dorsiflexion, invers. & evers. |
None |
L5-S1 |
SI |
Back of thigh, lateral posterior calf, lat. foot |
Posterolat. calf, lat and sole of foot, smaller toes |
Gastrocnemius • foot eversion |
Achilles |
(Nb. lumbar disk protrusion tends to compress the root corresponding to the level of the vertebra below it)
(Nb. lumbar disk protrusion tends to compress the root corresponding to the level of the vertebra below it)
Treatment
• Conservative: avoid bending lifting; NSAIDs
• Spinal epidural steroid injections: radicular pain refractory to medical management
• Surgery: cord compression or cauda equina syndrome (see below); progressive loss of motor function; bowel or bladder dysfunction; failure to respond to conservative therapy (NQM 2007:356:2245)
Cord Compression
Clinical manifestations
• Flaccid paraparesis and absent reflexes if acute
• Spastic paraparesis and hyperactive reflexes if subacute to chronic
• Posterior column dysfunction in legs (loss of vibratory sense or proprioception)
• Bilateral Babinski responses
• Conus medullars syndrome: symmetric saddle anesthesia, bladder & bowel dysfunction
(urinary retention. I anal tone), absent bulbocavernosus and anal reflexes
• Cauda equina syndrome: severe back pain, leg weakness and or sensory loss, r i reflexes in lower extremities, relative sparing of bowel & bladder function (but occurs)
Evaluation and treatment
• STAT MRI and neurology consultation
• Empiric dexamethasone 10 mg IV or methylprednisolone 30 mg kg IVB over 15 min
— 5.4 mg kg h starting 45 min after bolus and continuing for 23 h
• Emergent radiation therapy ; surgery for compression due to metastatic disease
• Emergent neurosurgical consultation
Spinal Stenosis
Clinical manifestations
• Neurogenic claudication back or buttocks pain induced by walking or prolonged standing, relieved by bending forwards and by rest
• ± Focal weakness, sensory loss, diminished reflexes
• Unlike claudication: max discomfort in anterior thighs, preserved lower extremity pulses
• Unlike disk herniation: pain relieved by sitting
Evaluation
Treatment
• Conservative: avoid bending lifting; NSAIDs
• Surgical decompression if failure to respond to conservative therapy (NEJM 2007J56:2257)
NOTES
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Deal With Your Pain, Lead A Wonderful Life An Live Like A 'Normal' Person. Before I really start telling you anything about me or finding out anything about you, I want you to know that I sympathize with you. Not only is it one of the most painful experiences to have backpain. Not only is it the number one excuse for employees not coming into work. But perhaps just as significantly, it is something that I suffered from for years.
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