Back Pain: Part Tres

I worked the overnight night shift last night in the acute coronary unit and now my sleep schdule is all messed up. It wasn't too terrible of a night: two admission with one pt having pneumonia and shortness of breath and another with a retroperitoneal hematoma a couple days after a normal cath. No codes. No lines to put in. Tho I am wondering about the extremely hypokalemic pt in renal failure. Oh, and the nosebleed who had some pseudothrombocytopenia. Nothing too exciting.

So before we move on to another episode of back pain, I've probably read about 100 pages to far which means that only like 5% done with the book. Well, at least there are still 360 days left in the year. =)

More causes of back pain:

Veterbral osteomyelitis
-usually from a staph infection but can also be secondary to a UTI, PNA or cellulitis
-IVDA is a risk factor
-if it is pyogenic, check for endocarditis!!
-pain is worse with motion, tendernes usually seen over segment
-fever present, elevated ESR, increased WBC
-check CT or MRI, x-ray can take months or years to show narrowed disk spaces with erosion

Spinal epidural abcess
-back pain with movement and palpation, fever
-check MRI
-may or may not have spinal cord compression or nerve root injury

Lumbar adhesive arachnoiditis
-fibrosis s/p inflammation of subarachnoid space
-leg and back pain iwth motor, sensory, or reflex changes
-MRI shows clumped nerve roots or loculations of CSF in the thecal sac
(clumped nerve roots are also seen in demyelinating polyneuropathies and neoplasms)
-Treat with surgery, dorsal column stimulation or epidural injection, but none have been proven to work

Compression fracture
-back or leg pain worse with movement and reproducible on palpation
***compression fractures above the mid-thoracic region suggest malignancy***
check for the primary tumor!!
-tx: percutaneous vetebropasty (PVP)
-candidate for PVP if:
+ midline back pain
+ tenderness on palpation
+ <80% height loss of veterbral body
+ onset within 4 months
-PVP involves injecting polymethylacrylate into the vetrebra
-PVP may be done with kyphoplasty which inflates a balloon in the vetebral body prior to cement injection

***Sudden lumbar pain in a patient receiving anticoagulant --> Suspect retroperitoneal hemorrhage!!***

- AAA rupture presents as isolated back pain in 15% of cases
- the classic ab pain + shock + back pain happen in <20%
- pt is typically an elderly male smoker
- check for a pulsatile mass and check CT

-IBD or cancers can have a pain in a belt-like distribution

The Big List of Risk Factors in Acute Back Pain
- pain worse at rest or at night
- prior history of cancer
- history of chronic infection (esp lung, UTI, skin)
- history of trauma
- incontinence
- age >50 y/o
- IVDA
- glucocorticoid use
- h/o rapidly progressive neuro defect
- unexplained fever
- unexplained weight loss
- percussion tenderness over the spine
- abdominmal, rectal, or pelvic mass
- patrick's sign or heel percussion sign
- straight leg or reverse straight leg raising sign
- progressive focal neurologic deficit

Good Treatents for Acute Low Back Pain
- cervical collars
- heat

Questionable Treatments
- ice
- biofeedback

No proof treatments
- acupuncture
- TENS
- massage
- ultrasound
- diathermy
- magnets
- electrical stimulation

Not recommended
- facet joint injections
- trigger point injections
- ligament injections

Medical Treatment
- NSAIDS/Tylenol
- Cyclobenzaprine - start with 10mg qhs and can go up to TID, should see benefits in 4-7 days esp if sleep is affected, limited use by daytime drowsiness
- opioids should only be used short term if indolent or pt unresponsive to acet/NSAIDS
- no evidence for the use of TCAs or oral glucocorticoids
- Epidural glucocorticoids provide short term relief for ALBP with radiculopathy
- Nerve root blocks can be used for temporary pain relief

Spinal manipulation and PT are reasonable therapies for ALBP

Chronic back pain
-defined as pain >12 weeks

A study done on chronic sciatica showed that surgery hastened relief of symptoms by 2 months but at one year there was no difference

Do not exceed more than 2 weeks bed rest in treating back pain

Questionable prrof for chronic back pain
- back school, manipulation, epidural steroids, TENS, hydrotherapy

No evidence in treating chronic back pain
- acupuncture, traction