Back Pain
History
Acute or chronic?
Onset?
Rapid onset associated with lifting or twisting movements, is more likely to result from mechanical stress, while an insidious onset suggest a tumor.
Pain characteristics: ChLoRIDE PP.
Mechanical vs. non-mechanical pain
Change with sitting, standing, flexion or extension of spine. Pain intermittently associated with activity suggest mechanical stress. Constant, aching, unrelenting pain suggests a non-mechanical source.
Region refers to precise localization of the pain with a finger to the site of maximum intensity.
Back pain with radiation to a dermatomal distribution suggest specific nerve root irritation.
Tearing chest pain radiating to back to the interscapular region is aortic dissection unless proven otherwise. If patient also has similar type, associated with abdominal pain radiating to the lumbar regions, and lower back, think again Ao dissection or expanding AAA which may be leaky.
H/o trauma.
Alarm symptoms- age>50, night pain, bowel/bladder dysfunction, motor weakness, h/o IVDA, h/o cancer and wt loss. H/o fever, chills. Dysuria, hematuria, pyuria, dull flank pain, loin to groin colicy pain.
Cauda equina syndrome, epidural abscess, vertebral OM, pyelonephritis, ureteric colic.
Anticoagulants use - epidural hematoma.
Any stiffness and other joint involvement?
PMH: DM, HTN, heart disease, pulmonary, kidney disease, immunocompromised, malignancy (vertebral metastases), autoimmune disease.
PSH: epidural anesthesia, lumbar puncture, lumbar drain, post-operative complication of spinal surgery.
Occupation of the patient (past and present).
Any signs/symptoms of depression?
Narcotic and non-narcotic pain medications used in the past.
IVDA
Any other pain relieving measures used?
Any worker’s compensation, legal issues and disability involving back pain?
Physical Exam
VS: fever, HTN. Check for discrepancy of BP in both arms.
General appearance: Pacing, writhing: kidney stone
Inspection:
Skin: erythema, rash (vesicular - herpes zoster), warmth, redness over spine (abscess, OM).
Gait, movement, any muscle atrophy, fasciculations, curvatures of the spine.
Abdominal pulsations.
Examine LE: pulses.
Palpation
Start away from the area of tenderness. To precisely describe the location of tenderness, find the tops of the iliac crest with fingers of the palpating hand and place the thumb at the level of L4-L5 junction. Palpate superior to this landmark, counting the spinous process on each vertebra.
Vertebral, paraspinal muscle or sacroiliac joint tenderness, CVA tenderness.
Abdominal pulsation, and distal pulses
Auscultation: Heart murmur. Abdominal bruit.
Neuromuscular exam
SLR, crossed SLR: stretches the sciatic nerve
Pain reproduced by SLR may indicate sciatic nerve root irritation. Test is performed with the patient in the supine position. The examiner alternately lifts each of the patient's legs while supporting the calcaneus with one hand and holding the ipsilateral knee straight. Dermatomal pain elicited at 30° - 70° radiating below the knee indicates a positive test.
Great toe (L5) and ankle dorsiflexion and inversion - tibialis anterior (L4, L5)
Knee reflex L2- L4
Ankle reflex L5-S2
Hamstring reflex
Adductor reflex L2-L4
Power in all muscle groups
Sensory exam-dermatomal, rectal, perianal sensations.
Light touch, vibration, and joint position
L4: sensation in the medial aspect of leg.
L5: sensation over the dorsum of foot.
S1: sensation over the lateral aspect of foot.
S2,3,4: anal wink
Range of motion of the spine, flexion, extension, lateral rotation, and lateral flexion.
Digital rectal exam to check for rectal tone, diminished perinanal sensation, and enlargement or nodularity of the male prostate gland.
Investigations:
X-ray for pts with alarm symptoms and for chronic LBP
CCP, CBC, Alk phos, ESR, Urine and serum electrophoresis
US - AAA (unstable patients), TEE for Aortic dissection (unstable patients). CTA for stable patients with AAA, Ao dissection.
CT/ MRI of the spine, for back pain with fever, history of immunocompromise or IVDA, and neurologic deficit.
Neurosurgery consult for suspected cauda equina syndrome.
Empiric ABx, IV with adequate coverage for S. aureus, if epidural abscess suspected.
Aortic dissection: BB, nitroprusside IV, or labetalol as monotherapy agent.