Back pain/Musculoskeletal pain/Sciatica

Back pain/Musculoskeletal pain/Sciatica:

  • Assess for “red flag” signs/symptoms to raise suspicion for malignancy, spinal infection, fracture, and cauda equine syndrome and need for early imaging: weight loss, back pain waking patient from sleep, neurological deficits -> perform diagnostic imaging (MRI) to assess.
    • “Red flags” of cauda equine syndrome:
      • Urinary incontinence or retention
      • Diminished perineal sensation (“saddle anesthesia”)
      • Bilateral motor deficits
    • ***Surgical emergency! (along with other causes of spinal cord compression)
      • Emergent MRI of the entire spine -> Consult surgery stat!
      • Start dexamethasone.
  • Consider herniated disk (acute back pain radiates down a leg):
    • Positive Straight Leg test.
    • Weakness of the ankle and great toe dorsiflexion (L5)
    • Loss of ankle reflexes (S1)
    • Loss of knee reflex (L4)
  • Consider spinal stenosis:
    • Older patients.
    • Neurogenic claudication: radiating back pain and lower extremity numbness
      • Exacerbated by walking and spinal extension (transient cord compression).
      • Improved by sitting and leaning forward (decrease pressure on spinal cord).
    • Highly specific for spinal stenosis: a wide-based gait and abnormal Rhomberg test
    • Diagnose: MRI of the back.
    • Treat: Surgery (greater improvement in pain and function at 2 years compared to no surgery)
  • Most (85%) of back pain is nonspecific low back pain:
    • *** Do NOT order imaging for NONspecific low back pain.***
    • No matter that treatment selected, most acute low back pain will resolve rapidly.
    • Treatment: (sciatica: treat conservatively too – improves within 1-3 months)
      • 1st: self-care = remain physically active and apply heating pad to region.
      • Other interventions: medications (NSAIDs/Tylenol), massage, spinal manipulation.
        • Muscle relaxants and benzo: modest benefit but cause dizziness and sedation.
        • Physical Therapy
        • Low back stretches
    • If really significant pain, can consider Tramadol for a few days – week (not long term).

Neuropathic pain:

  • Gabapentin/Lyrica
  • Amitriptyline (constipation is a common side effect, consider ordering with Senna)
    • Could also try Nortryptyline (less side effects but possibly less effective)

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