Lower Back Pain John D. Peralta Family Medicine Resident PGY 3 Cook County-Loyola-Provident

Objectives Teach resident how to: 1. Classify lower back pain 2. Performed efficient interview and physical exam during initial evaluation 3. Narrow differential diagnosis based on clinical evaluation

Types of Lower Back Pain Acute 0-4wks Sub acute 4-12wks Chronic >12 wks

History:

Task to be complete during HPI Rule out possible potential serious life treating conditions Rule out organic causes or referral back pain

Potential Serious Spinal Conditions Possible etiology History findings Physical examination CANCER History of cancer, unexplained weight loss Others ( pain at night, age <20 or >50) Lymphadenopathy Cauda Equina Syndrome Bladder or bowel incontinence, urinary retention, progressive motor or sensory loss Major motor weakness or sensory deficit, loss of anal sphincter tone, saddle anesthesia

Potential Serious Spinal Conditions Possible etiology History findings Physical examination FRACTURE Significant trauma related to age, prolonged used steroids Others age >70, h/o osteoporosis Vertebral tenderness INFECTION Lumbar spine surgery during last year, IV drug used, immunosuppression Fever, infected wound in spinal region

Screening for : Anxiety Depression Panic disorders Addiction

Pain Specifics: Quality: sharp, dull, shooting, burning, etc. Location / Distribution: Radicular: Dermatomal distribution Radiating: Nondermatomal Onset: Gradual: Acute: Disc abnormality, strain, compression fractures Severity / Intensity Frequency: Constant vs. Intermittent Duration Exacerbating and Alleviating Factors Time of Day: If nocturnal, consider malignancy

Physical Exam:

Summary Pain can be classify in acute, sub-acute and chronic Potentially Serious Spinal Conditions most be rule out during initial evaluation At the end of our initial encounter we most differentiate the LBP in: Serious Spinal Back pain Sciatic Back pain Nonspecific Back pain

Reference Assessment and Management of Acute Low Back Pain. AAFP article Chronic Lower Back Pain: Evaluation and Management. AAFP article Diagnosis and Treatment of Low Back Pain; A joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society Tarascon Sports Medicine 2010