Family Medicine: Lower Back Pain

Front 1

Distinguish, by history and physical examination, low back pain secondary to systemic disease from back pain due to regional musculoskeletal origins, utilizing age, sex, and
occupational risk criteria in their clinical reasoning.

Back 1

Fever, weight loss, loss of appetite, elevated sed rate, anemia, elevated alkaline
phosphatase, and lymphadenopathy, elevated PSA.

Front 2

Distinguish typical symptoms and signs of complicated (disc/nerve root involvement)
from those typical of uncomplicated (muscular/mechanical) low back pain.

Back 2

Signs of nerve root involvement, such as: dermatomal radiation, positive SLR test, and
other neurological changes.

Front 3

Formulate appropriate plan of management of patients with low back pain which
incorporates an awareness of the patient's occupation, home situation, and minimal use of
pharmacologic agents.

Back 3

Usually includes bed rest on firm mattress or “bed board” and ice massage the first few
days followed by heat, anti-inflammatories, non-narcotic analgesics, and gradual
increase in activity. Discussion of weight loss in patients whose weight is greater than
recommended for height. Early physical therapy. Consider ergonomic evaluation
referral.

Front 4

A 40-year-old man with 2 days of lumbar back pain after lifting his television set.
He complains of pain in the right lower back area. He smokes and has no other
significant history. On physical exam the only significant finding is a positive
straight leg test. What is the next step in this patient’s management?

Back 4

This man has musculoskeletal low back pain without neurological defect. Imaging
studies, such as a plain film would not be appropriate. Conservative treatment with
anti-inflammatory medicines and back exercise is appropriate. If the pain does not resolve in four weeks consider further work-up

Front 5

An 8-year-old boy brought in by his mom after a fall from the monkey bars. He has pain in the mid-thoracic spine and no other complaints. On physical exam, he
has a great deal of pain with palpation of the mid-thoracic spine. His neurological
and physical exams are normal. What is the next step in the management of this
patient?

Back 5

Imaging studies (radiograph of thoracic spine) are indicated because of this patient’s age and the likelihood of spinal fracture.

Front 6

A 65-year-old woman with three months-worsening back pain in the lumbar area.
She is obese but has lost 20 pounds without trying in the last month. She has not
seen a doctor in several years because she has had no health care coverage. She
recently qualified for Medicare. Her past medical history is significant for intermittent
low back pain over the last 30 years. On physical exam she is an obese female with
exquisite tenderness on palpation of the lumber spine. What is the next step in the
management of this patient?

Back 6

Imaging studies, starting with lumbar spine films are indicated for this patient
because of her age. Diagnostic tests such as a CBC and ESR are also indicated.

Please note, because of the lack of insurance she has not been able to obtain routine preventive services. The patient has breast cancer with metastases to her spine. She had never had a mammogram.

Front 7

What does a straight leg test tell you?

Back 7

sensitive test for nerve root compression in L5/S1

Front 8

How do you test an intact L4 nerve? (motion, sensation, reflex)

Back 8

L4 = ankle dorsiflexion (up), sensation in anteromedial leg, patellar knee jerk

Front 9

How do you test an intact L5 nerve? (motion, sensation, reflex)

Back 9

L5 = dorsiflexion of the ankle and big toe against resistance, sensation of lateral shin and dorsum (top) of foot.

Front 10

How do you test an intact S1 nerve? (motion, sensation, reflex)

Back 10

S1 = ankle plantar flexion, ankle deep tendon reflexes, sensation in lateral foot and heel.

Front 11

When do you order X-rays of the back?

Back 11

Only do lumbar films if pain persists for 3-4 weeks, unless you suspect compression fracture, infection, or tumor.

Front 12

When do you pursue MRI for lower back pain?

Back 12

MRI is indicated if a patient with rediculopathy has failed conservative treatment (rest, PT, NSAIDs) or if they have any neuro symptoms.

Front 13

Outline general treatment for musculoskeletal back pain

Back 13

Most patients with or without radiculopathy are best managed conservatively with NSAIDs, brief period of rest and judicious use of narcotics and muscle relaxants if necessary.

If neurologic symptoms  MRI

Chronic low back pain = physical therapy, NSAIDs, epidural steroid injections

AVOID prolonged inactivity (leads to deconditioning). In the first week, attempt a walking routine.