Canadian Conference: Back Pain Jeopardy

Back Pain Trivia

100

These A delta and C fibers transmit signals to the dorsal column during pain.

What is a Nociceptor?

200

Back and neck pain is an expensive malady. How much money is spent on diagnosing, treating, and lost productivity in the U.S. per year? Is it $10-20B, $20-30B, $30-40B, or more?

What is $100-200B. This includes lost productivity of over 100 million days. Second only to heart and vascular disease. On par with cancer. 5% of the chronic back pain patients account for 75% of the cost.

300

Back pain is a common presenting problem to FM offices. What portion of all PCP visits are related to back pain? Is it: 1%, 5%, 10% or more?

What is 5%. Number 2 reason for PCP office visits. 85% of people have back pain at some point in their lives. 85% of visits for back pain are diagnosed as "non-specific" causes (sprain and strains). Chronic back pain is defined as pain greater than 12 weeks. Most common age for back pain is 45-60.

400

Back pain commonly resolves over time. What percentage of back pain patients will recover (full functionality) in less than 3 months? Is it: Les than 25%, 25-30%, 31-40%, 41-50%, greater than 50%?

What is 90%.

500

Approximately how many chiropractors are in Lincoln, NE? Is it: <50 51-75 76-100 101-150 >150

>180 (Yellow Pages)

Red Flags

100

Which of the following symptoms is considered a Red Flag for back pain? Is it: 1.Burning sensation in leg 2. Constipation 3. 28 y.o. male FM Resident who fell down playing in basketball league and finished 2 more games. 4. Mild weakness sensation in right leg, for 1 week. Patient is ambulating and able to get out of the exam chair unaided. 5. Past Medical History of prostate cancer, back pain for 6 weeks without injury.

5. PMH of prostate cancer

200

Which of the following is considered a Red Flag, select all that apply? 1. 72 y.o. fell on ice, moderate pain. 2. 64 y.o. female, back pain without injury, 2 weeks duration. 3. 42 y.o. male, history of laminectomy 2 years ago, now with back pain, fevers to 102F and chills with no other source illness. 4. 64 y.o. male urinary retention per u/s, 400cc post void. His back hurts off and on chronically, no weakness in legs, no numbness. 5. 38 y.o. female, in to see you for 3rd time, over 6 weeks for back pain. It's causing progressive weakness in her ankle to the point her foot is dragging when she walks and she trips a lot.

1, 3, 4 and 5

300

Your patient, 48 year old male, has seen you twice in the last moth for back pain. He reports that he cannot seem to urinate despite straining for 36 hours. He has also leaked stool into his clothes and didn't even feel it. In this case, what are your concerns/ presumptive diagnosis and what evaluation will you undertake with the what level of acuity?

Concerned for Cauda Equine syndrome. Admission or transfer to facility with spine surgery capabilities. Needs emergent MRI scan and surgical care.

400

These are the two differentials for back pain that require immediate referral.

What are Cauda Equina syndrome and Infectious sources of back pain?

500

This structure of vessels allows for spread to the vertebral bodies of pelvic origin cancers. The classic example of this is the osteoblastic lesions of the vertebra from prostate cancer spread.

What is Batson Plexus?

Diff Dx

100

What are the three categories our reference article uses for Differential Diagnosis and list 2 examples of each.

Intrinsic (DJD, Compression fracture, herniated nucleus pulposus, lumbar strain/sprain, spinal stenosis, spondylolisthesis, spondylolysis, osteomyelitis, diskitis), Systemic (Connective tissue disease, inflammatory spondyloarthropathy, malignancy), and Referred (Abdominal aortic aneurysm, GI conditions: Pancreatitis, PUD, cholecystitis. Pelvic conditions: endometriosis, PID, prostatitis. Retroperitoneal conditions: Renal colic, pyelonephritis)

200

This serious lower motor neuron lesion disorder causes loss of function of the lumbar plexus nerve roots and without emergent surgical involvement can result in incontinence and possibly permanent paralysis of the legs.

What is Cauda Equina syndrome?

300

This is the most common of the seronegative spondyloarthropathies and although occasionally symptoms can include peripheral joints, they are typically affect the back in males more than females between the ages of 30-40 and typically present in a slightly flexed trunk position. 90% patients HLA-B27 + (not specific because 10% of population + for HLA-B27)

What is Ankylosing Spondylitis?

400

This potential cause of spinal pain is typically without pain with elevated alkaline phosphatase, characteristic findings on plain xrays films of skull and long bones and treatment for those symptomatic may include calcitonin or bisphosphonates.

What is Paget's disease

500

This syndrome is not very common. It usually follows an infectious disease of GI system or GU. Pain usually localized to the lumbar spine. Look for mucocutaneous lesions on mouth, genitals, palms, soles and nails. ESR variably elevated and synovial fluid analysis shows elevated WBC count. SI joint most common site of pain.

What is Reiter's Syndrome

Anatomy, Symptoms, and Physical Exam

100

Define the mechanics and demonstrate a proper straight leg raise test and what constitutes positive or negative findings. What nerve root level is indicated by a positive test? What motor deficit may be adversely affected by a patient with a positive test? What reflexes would be affected?

Supine. Flex hip with knee extended and record the angle of induction of radiculopathy and the distribution. A neg test would be failure to radiate below the knee when hip flexed to limit of hamstrings tension , about 70 degrees. A positive test would be exacerbated by dorsiflexion of the ankle and would be relieved by knee flexion. L4-S1 spinal roots are culprits in a positive test. Motor deficit: L4 - Knee extension. L5 - Ankle dorsiflflexion, great toe extension, S1 - Plantar flexion. Reflexes affected. L4 - Patella, L5 - medial Hamstring, S1 - Achilles tendon

200

Define and demonstrate a reverse straight leg raise test. What constitutes a positive and negative test? What nerve roots are being tested? What muscles and reflexes would be affected?

Prone, extend hip with knee flexed to 90. Positive: radiation to thigh. Nerve roots are: L1-L3 Reflexes affected are patellar, L3. Muscles affected would be hip flexors and iliopsoas, adductors of hip(L3).

300

Explain and contrast the concept of spinal cord impingement by central disc extrusion vs anterolateral or lateral (foramina). In other words, how does the region of cord impinged affect the clinical presentation of radiculopathy, reflexes affected and weakness. At what level of the vertebral spine does the spinal cord proper terminate? What would be the clinical scenario of a central disc extrusion in to the spinal canal at S1?

Spinal nerves exit the spinal canal at a level of 1-2 vertebral bodies below the lumbar disc. So a higher segment of central disc extrusion can mimic a nerve root impingement 1- 2 levels lower. The cord terminates in most people at L1 vertebra. S1 central canal disc extrusion would be a cause of the Cauda Equina Syndrome.

400

List the pain region, sensory region, motor weakness and reflex changes of L4-5 disc extrusion to the right lateral.

What is: Pain:posterolateral aspect of thigh Sensation:Lateral leg, dorsum of foot, first toe Motor:Great toe extension, ankle dorsiflexion, heel walking difficulty (foot drop) Reflex: Minor

500

List the pain region, sensory region, motor weakness and reflex changes of L5-S1 disc extrusion to the right lateral.

What is: Pain: Posterolateral aspect of thigh and leg to heel Sensory: Posterior calf, lateral foot Motor: Calf, plantar flexion foot, great toe, toe walking Reflex: Ankle jerk

Evaluation and Management

100

List the commonly accepted indications for an MRI scan.

What is: Presence of red flags. 6 to 8 weeks or progressive or persistent radiculopathy with muscles weakness or parasthesias. MRI's rarely discover unsuspected etiologies of back pain, they usually confirm clinical suspicions and affirm the pathology for surgical treatment.

200

Describe a plan for suspected back strain, second visit, 4 weeks since injury. Patient has taken NSAIDS only.

Reaffirm musculoskeletal etiology. Consider limited evaluation if unclear of secondary causes. Reinforce careful lifting, consider work limitations if heavy laborer, consider referral to P.T. for back program or Chiropractic or masseuse based on patient preference, try different NSAID, add muscle relaxer at hs if sleep disturbance. Schedule f/u in 4 weeks to confirm resolution and return to unrestricted duty.

300

Regarding epidural injections: What are the indications to recommend a trial of injection? How affective are epidurals in the relief of back pain?

Radiculopathy unrelieved with 4-6 weeks of conservative therapy with MRI findings of impingement on neuroanatomy consistent with the patients symptoms. They are about 50% effective. A trial of 2 injections is reasonable if the first shot was somewhat helpful. The cost is $2,000 or more. Physiatrists, Radiologists, and Spinal surgeons usually are trained for this service.

400

Regarding Epidural Injections. What criteria are the most important in patient selection. What is the general range of success clinically. How many injections are typically performed. Is there radiation exposure involved?

Younger, motivated, well educated patients with mainly radicular pain, best if unilateral without localized back pain. Best if duration less than 6 months. Best if no secondary gain issues, like lawsuits, employment disability. The success can range from 70-84%. Typically up to 3 injections are offered. Best if done with fluoroscopy, there are 3 approaches to deliver the steroid near the nerve root in question or extruded disc.

500

This widely accepted method of assessment and treatment for back pain that has been used for over 30 years and was developed by a New Zealand Physiotherapist. This method includes assessment, classification, treatment and prevention. This may decrease recurrent pain and the need for health care services.

What is the McKenzie method?