Back Pain: Part Deux

So I came home after the gym today and took a nice nap and now here I am trying to stay up most of the night because I got pulled to do an overnight shift tomorrow. Today I worked with HIV and hep C patients. (separate clinics, not co-infected patients). With the hep C patients we do a lot of counseling to make sure patients are ready for treatment before actually starting since the treatment is a pain in the ass. Usually they meet with a psychiatrist, nurse, and case manager and us before the first meeting. Then we start peg-interferon which is a weekly shot and ribavirin which is a twice daily pill. Patients usually feel like they have the flu for a couple hours or a couple days every time after they get the shot. If they have an depression, it can get worse, hence the psych eval before treatment. There are also problems with neutropenia & anemia. It sounds like such a pain in the butt (being sick one day a week!), but the good news is that after 4 weeks, we get a good idea of the patient's chance for cure. But back to back pain...
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Causes of back pain- some can be congenital anomalies such as spondylolysis which is a defect between the pedicle and laminae, usually seen in young adults
- spondylolisthesis is anterior slippage of the vetebral body . a "step" may be palpated on spinal exam

Tethered Cord Syndrome
-presents as a progressive cauda equina syndrome or possibly myelopathy
-pt is often a young adult who c/o perianal pain some time after minor trauma
-neuroimaging reveals low-lying conus (below L1-2) and short thickened filum terminale

Trauma
-sprains and strains
-traumatic vetebral fractures - usually from ant wedging or compression

Lumbar Disk Disease
-usually at L5-S1 level and seen more in obese patients
-symptoms include back pain, abnormal posture, limitation of spine motion (esp flexion) or a radicular pain. Can have a dermatomal sensory loss or absent deep tendon reflex suggests specific nerve root. Motor sx less common and usually unilateral, but can be bilateral if herniation is big.

Indications for Surgery with Lumbar Disk Disease
1. increased weakness (on exam or on EMG)
2. sphincter abnormalities
3. incapacitating pain after more than 4 weeks of treatment
4. receurrent incapacitating pain

Cauda Equina Syndrome
-usually secondary to a msss lesion
-presents with saddle anesthesia, areflexia, weakness, loss of bowel or baldder function, low back pain
-r/o transverse myelitis & GBS
- Tx: surgery (or radiation if there is a tumor present)

Spinal stenosis
- characterized by pain worse with standing and better with sitting
- pain typically in back, butt, and leg
- Tx: NSAIDs, exercises, surgery if refractory
- check MRI for imaging

Spondylosis = arthritic spine disease
- seen later in life
- cervical and lumbar involvement
- back pain worse with movement and associated with stiffness
- no straightforward correlation with radiology

Ankylosing Spondylitis
- seen in men less than 40 years of age
- morning stiffness, no relief with rest
- nocturnal pain, better with exercise
- loss of lumbar lordosis and increase in thoracid kyphosis can be seen

Neoplasms
- usually constant dull pain, worse at night
- not better with rest

Mechanical back pain
- better with rest
- no radiation

That's all for now. I'm gonna go read and then maybe we'll get back for part 3!