Case Study: Back Pain Nursing 870

The Case 87 y/o white female with lumbar back pain over 2 weeks. Worse last 4 days to the point of not being able to walk due to the pain. Slid on to floor 2 weeks ago. No previous problems ambulating in the past. PMH scleroderma of skin(psoriasis), Unsure whether saw PMD or therapist within the last week. Meds: Steroid cream PE: Essentially negative except neuro examine: able to lift legs off the bed. Toes downgoing. Reflexes not noted.

What Other History Components are Missing?

History and Red Flags Injury? Any red flag associated signs/symptoms? Cancer Fever Unexplained weight loss Pain duration > 1 month or failure to improve with 1 mo treatment Age > 50 History of cancer Bed rest without relief

History and Red Flags Osteomyelitis Compression fracture History of drug abuse, UTI, or skin infection Compression fracture Age > 50 (some studies > 70) Corticosteroid use Herniated disc Sciatica Cauda Equina syndrome Bladder or bowel dysfunction Urinary retention with overflow incontinence Saddle anesthesia

History and Red Flags Spinal stenosis Ankylosing spondylitis Pseudoclaudication Pain with walking, relieved by rest Age > 50 Pain relieved with sitting or spine flexion Ankylosing spondylitis Age at onset < 40 Pain not relieved in supine position Morning back stiffness Duration of pain > 3 mo.

The Case What diagnostic tests are indicated here?

Diagnostics

The Case Pt admitted without x-rays and labs? Pt with progressive paresis of lower extremities and developed a fever that night in the hospital. MRI the next day demonstrated epidural abscess. Patient requires immediate surgical intervention. Epidural Abscess grows MRSA. Pt using steroid cream on skin for psoriatic rash daily like skin lotion. It is believed patient made herself immunosuppressed and probably had a hematogenous spread of infection from skin to spine.

Back Pain 5th most common symptom for all primary care visits Estimated that 84% of adults will have back pain at some point < 5% of patients with serious pathology

Risk Factors Risk factors for the onset of back pain include: Smoking Obesity Older age Female gender Physically strenuous work Sedentary work Psychologically strenuous work Low educational attainment Workers' Compensation insurance Job dissatisfaction Psychological factors: somatization disorder, anxiety, and depression

Key History Questions to Rule Out Red Flags Is there evidence of systemic disease? Is there evidence of neurological compromise? Is there social or psychological distress that might contribute to pain?

The PE (Recommendation 1) Focused PE Should Include: Inspection of back and posture Range of motion Palpation of the spine Straight leg raising (for patients with leg symptoms) Neurologic assessment (for patients with leg symptoms) L4: knee strength and reflexes L5: great toe and foot dorsiflexion strength S1 : foot plantar flexion and ankle reflexes Evaluation for malignancy (breast, prostate, lymph node exam) when persistent pain or history strongly suggests systemic disease Peripheral pulses should be evaluated in older patients with exercise-induced calf pain to rule out vascular claudication. Range of motion in flexion and extension does not reliably distinguish among pathologic causes, but can provide a baseline to use as an index of therapeutic response. Limited lumbar flexion is not sensitive or specific for diagnosing ankylosing spondylitis. Palpation of the back is usually performed to assess vertebral or soft tissue tenderness. Vertebral tenderness is a sensitive, but not specific, finding for spinal infection [50]. However, the finding of soft tissue tenderness is poorly reproducible among observers .

PE Categorizes patients into risk categories Non-specific (> 85% of cases) Associated with radiculopathy or spinal stenosis (6- 10%) Other causes

PE Consider Fibromyalgia https://www.accp.com/docs/bookstore/acsap/a15b1_m1sample.pdf

Diagnostic Testing Not indicated in first 4-6 weeks unless: (Recommendation 2) Progressive neurological findings Constitutional symptoms History of traumatic onset History of malignancy Age ≥50 years Infectious risk such as injection drug use, immunosuppression, indwelling urinary catheter, prolonged steroid use, skin or urinary tract infection Osteoporosis

Diagnostics X-rays CT MRI R/O tumor, fracture, infection, instability, spondyloarthropathy, and spondylolisthesis CT MRI Plain radiographs — If clinical improvement has not occurred after four to six weeks, plain anteroposterior and lateral radiographs of the lumbosacral spine may be useful (two views total). The goal of radiography is to rule out tumor, infection, instability, spondyloarthropathy, and spondylolisthesis. Joint guidelines from the American College of Physicians and the American Pain Society (2007) explicitly recommend that "Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain" and reserve imaging for patients with severe or progressive neurologic deficits or when serious underlying conditions are suspected on the basis of history and physical examination [60]. CT and MRI scanning Computed tomography (CT) and magnetic resonance imaging (MRI) are more sensitive than plain radiographs for detecting infection and cancer, and can show herniated discs and spinal stenosis. However, MRI or CT findings may be incidental and unrelated to the etiology of low back pain (table 7). (See "Diagnostic testing for low back pain".) Early or frequent use of scanning is not recommended for most patients. CT or MRI is indicated for progressive neurologic deficits, high suspicion of cancer or infection, and should be considered for those with more than 12 weeks of persistent low back pain. When available, MRI is preferred over CT scan for better visualization of soft tissue and absence of radiation exposure CT and MRI studies are more sensitive than plain films for detecting infection, cancer, disc pathology, and spinal stenosis. However, bulging discs are seen in more than 50 percent of asymptomatic patients; asymptomatic herniated discs are seen as well, though less frequently. Disc extrusions have more diagnostic significance than disc protrusions. CT or MRI is indicated for progressive neurologic deficits, high suspicion of cancer or infection, or after 12 weeks of persistent low back pain.

Diagnostics MRI preferred (Recommendation 3) Evaluate persistent low back pain and signs of symptoms of radiculopathy or spinal stenosis if they are candidates for surgery or epidural steroids Most patients symptoms subside or improve within 4 weeks

Treatment (Recommendation 5) Provide education about expected course Advise patients to remain active Provide information about self-care Heat No evidence to support ice Medium to firm mattress support Use of exercise Acupuncture

Medications Acetaminophen NSAIDs ( with or without PPI) No good evidence for usefulness for acute pain Useful in osteoarthritis NSAIDs ( with or without PPI) Nonselectives appear to more effective Provide better relief Good evidence for short-term effectiveness Opioid analgesics or Tramadol For severe disabling pain, short term For long-term use, chronic pain

Medications Skeletal Muscle relaxants Antidepressants (chronic pain) Tizanidine (Zanaflex): antispastic Others without good evidence Benzodiazapenes without good evidence Use associate with higher number adverse events Antidepressants (chronic pain) Tricyclics for chronic pain Good evidence Herbals Capsicum, devil’s claw, willow bark Systemic corticosteroids not recommended No good evidence

Non-Pharmacologic Treatments (Recommendation 7) Spinal manipulation PT (chronic or subacute) Exercise May start after 2-6 weeks; time unclear Massage therapy Yoga Cognitive-behavior therapy Progressive relaxation

Dual Therapy Tizanidine with acetaminophen or NSAID Greater short term pain relief than acetaminophen or NSAID alone Higher risk adverse events

Indications for Referral Neurosurgeon or Ortho surgeon specializing in backs Cauda equina syndrome – typical features are bowel and bladder dysfunction (urinary retention), saddle anesthesia, and bilateral leg weakness and numbness. The cauda equina syndrome is a surgical emergency. Suspected spinal cord compression – this may present as acute neurologic deficits in a patient with cancer and risk of spinal metastases, and requires emergent evaluation for surgical decompression or radiation therapy, with specific management determined by the underlying pathology. Progressive or severe neurologic deficit

Referral Patients may also be referred to a neurologist or physiatrist if any of the following are present: Neuromotor deficit that persists after four to six weeks of conservative therapy Persistent sciatica, sensory deficit, or reflex loss after four to six weeks in a patient with positive straight leg raising sign, consistent clinical findings, and favorable psychosocial circumstances (eg, realistic expectations and absence of depression, substance abuse or excessive somatization).

References Chou, R. & Huffman, L. H. (2007). Medications for acute and chronic low back pain: A review of therEvidence for an American Pain Society/American College of Physicians Clinical Practice Guideline . Annals of Internal Medicine, 147, 505-514. Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, T., Shekelle, P., & Owens, D. (2007). Diagnosis and treatment of low back pain: A joint guideline from the American College of Physicians and The American Pain Society. The American College of Physicians, 147, 478-491.