Assumptions
1. Students have a working knowledge of musculoskeletal anatomy of the spine.
2. Students have a basic understanding of disease spread (neoplastic, infectious).
Objectives
1. Elicit history and physical exam finding that permits a focused evaluation of back pain. Incorporate a detailed neuromuscular assessment.
2. Describe the key manifestations of various back pain syndromes. Consider: acute vs. chronic, age and gender, occupational & recreational risk factors.
3. Recognize radicular pain symptoms (herniated disc) and correlate neurologic findings with neuroanatomic level of disease.
4. Develop a differential diagnosis, initial evaluation and treatment strategies for:
 herniated disc
 spondylosis / spondylolisthesis
 scoliosis
 osteoporosis & degenerative disc disease
 primary & metastatic tumors of the spine
 infectious: osteomyelitis, epidural and paraspinal abscess
 traumatic (musculoskeletal strain, vertebral fractures/dislocation ± cord injury)
 retroperitoneal sources (aortic aneurysm, GU sources, pancreatic disease).
5. Discuss the use of diagnostic studies available for evaluation of back and leg pain. Include spine radiographs, CT scan, MRI, bone scan, myelography, angiography.
6. Discuss the indications for surgical consultation and treatment in problems addressed above.
7. List potential complication of surgery on the spine as well as unique concerns for perioperative management and rehabilitation / recovery.
Problems
1. A 42-year-old woman bends over to pick up a large potted plant and drops to the ground with severe pain in the lower back. In the ER she is in obvious distress and describes a sharp pain radiating down her right buttock and leg.
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What other questions you would like to ask regarding her history?
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What other findings do you expect on physical examination?
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What, if any, diagnostic tests are indicated?
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What would be you initial management options?
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Would your approach differ if she had numbness of the lateral leg and diminished DTRs? Loss of bowel and bladder control?
2. A 68-year-old man presents with back pain and weight loss. He notes a decline in physical activity over the past 4-5 months associated with a boring constant pain in his mid-back. He considers himself otherwise healthy and hasn’t seen a physician in 3 years.
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What else do you want to know?

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What is the significance of night pain associated with back pain?
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What if his exam revealed only an enlarged prostate with a palpable mass in the right lobe?
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What if his exam revealed a firm masses in the epigastrium that was non-pulsatile?
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What would your diagnostic approach be in each circumstance?
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What are your options for pain relief? Treatment?
Prevention
1. Describe methods for preservation of back function occupationally and during leisure activities as part of healthy lifestyles
2. Encourage screening studies for at risk populations: PSA, AAA, and osteoporosis