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Red flags for serious back pain

Red flags for serious back pain. Fever, weight loss Pain with recumbency, nocturnal pain Morning stiffness Persistent pain lasting > 6 weeks Age over 50 with new onset pain Abnormal neurology Point tenderness. Further evaluation.

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Red flags for serious back pain

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  1. Red flags for serious back pain • Fever, weight loss • Pain with recumbency, nocturnal pain • Morning stiffness • Persistent pain lasting > 6 weeks • Age over 50 with new onset pain • Abnormal neurology • Point tenderness

  2. Further evaluation • Goal is to discriminate between “ benign” cases and disorders that require further diagnostic studies • Radiological imaging: Xray/ CT Scan/ MRI • Useful lab tests: • FBC, ESR • Calcium, ALP • protein electrophoresis

  3. What should I be worried about? • Herniated disc • Spinal stenosis • Cauda equina syndrome • Inflammatory spondylarthropathy • Spinal infection • Vertebral fracture • Cancer • Referred visceral pain

  4. Imaging Studies: Spinal Stenosis • CT scan shows spinal stenosis due to hypertrophic changes in the facet joints • CT myelogram reveals canal occlusion with flexion due to spondylolisthesis

  5. Disk Herniation • MRI image shows a protruding disk (arrow) that compresses the thecal sac (short arrow)

  6. Ankylosing Spondylitis: X-Ray Changes

  7. Spinal infection — X-Rays

  8. Osteoporosis- X-Ray Multiple compression fractures

  9. Multiple Myeloma • RRed flags for spinal malignancy • PPain worse at night • OOften associated local tenderness • CFBC, ESR, protein electrophoresis if ESR elevated

  10. When is surgical referral indicated? • Sciatica and probable herniated discs • Cauda equina syndrome • Progressive or severe neurological deficit • Persistent neuromotor deficit after 4-6 weeks conservative treatment • Persistent sciatica with consistent neurologic and clinical findings

  11. When is surgical referral indicated? • Spinal Stenosis • Progressive or severe neurological deficit • Persistent back and leg pain improving with flexion and associated with spinal stenosis on imaging • Spondylolisthesis • Progressive or severe neurological deficit • Severe back pain/ sciatica with functional impairment that persists > 1 year

  12. Key Points about low back pain • 90% are due to mechanical causes and will resolve spontaneously within 6 weeks to 6 mths • Pursue diagnostic workup if any red flags found during initial evaluation • If ESR elevated, evaluate for malignancy or infection • In older patients initial Xray useful to diagnose compression fracture or tumuor

  13. Key Points about low back pain • Bed rest is not recommended for low back pain or sciatica, with a rapid return to normal activities usually the best course • Back exercises are not useful for the acute phase but help to prevent recurrences and treat chronic pain • Surgery is appropriate for a small portion of patients with low back pain

  14. Further reading • Deyo RA, Weinstein JN. Low back pain. NEJM 2001;344:363-370 • Malmivaara A, Hakkinen U, et al. The treatment of acute low back pain. NEJM 1995;332:351-355 • Borenstein DG. Low back pain. In:Klippel J , Dieppe P, editors. Rheumatology. London : Mosby; 1994. p.5.4.1-5.4.26

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