`Freeze` Template - PBL-J-2015

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
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
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
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
3) Other
3) Other
Management Plan
Goal/desired outcome
Method (incl. patient actions)
Movement for rehabilitation
Analgesia (see below)
Resources/health professional s
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
Time off work
Return to healthy weight
Prevention of comorbidites: circulatory
disease and/or diabetes
Return to work
Continued pain
Resolution of symptoms
Mode of action
Opiate analgesia:
Opiod receptor agonists: prevents
nociceptive transmission peripherally by:
*Inhibit neuroexcitation in pain fibres in
*Inhibit synaptic transmission at the dorsal
*Stimulate descending inhibitory pathways
at the NRPG and PAG
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,
Exercise physiologist
General practitioner
Exercise physiologist
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