Week 27: PBL 26 - 'Freeze' Acute exacerbation of Chronic, Non-Specific Low Back Pain Relevant Symptoms (incl. relevant negatives) Gloria, 47 y/o nurse: Severe Pain of sudden onset, emanating from the lumbar spine Radiating pain into (R) LL Reduced sensation in (RHS) shank and foot Reduced power in DF and PF Muscle spasm: Unable to move Negatives: No loss of urinary or faecal continence No recent trauma No Hx of cancer Patient under age 50 Other Significant History History of chronic benign low back pain post MVA (age 32) Widow, 3 children, no family support Pain evoked by movement Pain responsive to analgesia + rest Examination and Signs Moderately obese woman Afebrile PR: 90 | BP: 142/82 | RR: 16/min | Temp: not given Sensation: reduced in RLL (shank/foot) Pain: low back, radiates to RLL; exacerbated on hip flexion RHS w/ knee extended Reflexes: knee, ankle = normal Power: reduced in DF and PF (RHS) Lung fields clear Abdomen normal Provisional Diagnosis Differential Diagnoses Acute disc herniation CNSLBP (Chronic, non-specific low back pain) Compression fracture 2° to osteoporosis Compression fracture 2° to bony metastasis Stress fracture Spinal stenosis Disc prolapse Dissecting abdominal aortic aneurysm Inflammatory (rheumatoid) arthritis of spine Renal colic due to renal calculus Miscarried pregnancy Infective cause: epidural abcess Spinal tumour SIJ pain Musculoskeletal low back pain: muscle spasm, facet joint injury Risk Factors and Aetiology/Pathophys. Low back pain: Lifetime prevalence of 70-85% Most (90%) recover within 3 months, 5% never return to work Affects men more than women IV disc herniation/prolapse most common in 30-50y/o, occurs at L4-5 or L5-S1 levels 1. Previous history of low back pain 2. Obesity: prevalence of LBP correlates with BMI 3. Heavy physical work: frequent bending, twisting, and lifting 4. Prolonged static postures (sitting). 5. Psychosocial risk factors include anxiety, depression, and mental stress at work. Pain thought to arise from injury to annulus fibrosus, causing an inflammatory response which irritates nociceptors in the sinuvertebral nerve and lumbar sympathetic chain (of same nerve root level). Symptoms are dependent on the location and progression of the disc herniation. Compression of the nerve roots creates oedema, intraneural inflammation and hypersensitivty by inflammatory cytokines and endogenous chemicals (TNF-alpha, interleukins, Phospholipase A2, prostaglandins, NO, metalloproteinases, (?others, substance P?) Key Basic Science Learning Issues (incl. diagrams, mechanisms, concept maps if desired) 1) Anatomy Week 26: Spine and Spinal Cord CCS and Pathophys: Week 27: Low Back Pain CCS (see image adjacent) Week 27: Gait disorders Investigations and Results 1) Blood tests N/A Other possible investigations 1) Blood tests None necessary 2) Imaging Plain AP x-ray of lumbar and sacral spine MRI (T2 weighted image) of Lumbosacral spine: encorachment of the L3-4 disc onto right lateral vertebral foramen: L4 spinal nerve impinged 2) Imaging Bone scan in suspected metastasis CT 3) Other N/A 3) Other N/A Management Plan Problem Goal/desired outcome Method (incl. patient actions) Pain Movement for rehabilitation Analgesia (see below) Resources/health professional s involved Medical doctor Acute inflammation Restoration of functional capacities Rest; avoid aggravating activities Care team Fear of movement Movement rehabilitation programme Re-training of neuromuscular control of local and global muscles Medical doctor Physiotherapist Obesity Time off work Return to healthy weight Prevention of comorbidites: circulatory disease and/or diabetes Return to work Continued pain Resolution of symptoms Medications Mode of action Opiate analgesia: Opiod receptor agonists: prevents nociceptive transmission peripherally by: *Inhibit neuroexcitation in pain fibres in periphery *Inhibit synaptic transmission at the dorsal horn *Stimulate descending inhibitory pathways at the NRPG and PAG Notes: http://www.evernote.com/shard/s168/sh/e 870ff78-6287-46ea-80a3748acc94cee3/350e08ae0265529efea10f000 591c4ef Other Psychosocial/ethical/legal/patient-centred considerations - Chronic disease ----> see CD notes/LOs Chronic pain ----> see Hunter pain clinic video on wiki Worker's compensation PPH/PPD implications 50% yearly prevalence of low back pain in working age adults Learning correct lifting techniques Progressive resistance exercise ----? return to work Exercise therapy Dietary modification ?Worker's compensation claim? Modified duties Neurosurgery referral for microdiscectomy + repeat of rehabilitation process Side effects Constipation, respiratory depression, miosis, bronchoconstriction, bilary colic, nausea/vomiting, hypotension, ADDICTION Exercise physiologist General practitioner Exercise physiologist Dietician Medical doctor Neurosurgeon and/or spinal orthopaedic surgeon Any specific monitoring required? Use of opiods needs to be restricted and weaning from opiod medication needs to begin ASAP Impact on Aus healthcare budget = 15-20% of healthcare spending Worker's compensation: 40% of claims are spinal/spine related LBP = Most common cause of disability in under 45 Lack of effective treatments CCS: History and Examination of Lumbar Spine Resources used/discovered