Pain

Four Pain Cases worksheet (Required):  Pain Cases

Low Back Problems in Adults

_{Reprinted with the permission of Ron Adler, MD}

Low back problems are extremely prevalent and costly.

PCPs are ideally suited to being back problems experts.

The most important diagnostic instruments are the history and the physical exam.

A tiny percentage of primary care patients have serious conditions that can be suspected from the history.

Routine spinal imaging tests are NOT indicated. Imaging tests are indicated in the setting of red flags (refer to below) or severe problems persisting beyond 1 month.

Most back problems improve spontaneously; therefore, conservative management is almost always indicated.

The most important therapeutic instrument is patient education.

Most patients will have recurrent back problems.

A small but substantial percentage of patients will have chronic problems.

Early and gradual return to usual activities is superior to bedrest.

Initial Approach to the Patient

Is there a serious systemic disease causing the pain?

Is there neurologic compromise that might require surgical evaluation?

Is there social or psychological distress that may amplify or prolong pain?

“Red Flags (consider imaging)”

Cancer

Failure to improve (>1 month)

Prior history of cancer

Unexplained weight loss

Compression Fx

h/o osteoporosis

Corticosteroid use

Trauma

Elderly

Spinal Stenosis

Psedoclaudication

Leg pain on walking or

Relieved by sitting or standing

Ankylosing Spondvlitis

Onset <40 yo, gradual onset

Pain duration >3 months

Morning stiffness

Improved by exercise

Miscellaneous

Progressive pain

Urinary or fecal retention or incontinence

Neurological deficit

Fever and/or constitutional sx’s

Cauda Equina Syndrome

Nerve root compression causing urinary retention, bilateral weakness, saddle anesthesia.

Neuro-surgical emergency

Caused by massive midline disc herniation

Prevalence among all with LBP: 0.0004

Required Reading: Integrative Pain Management

Required Reading:   Acute Low Back Pain

Required Reading:  Chronic Nonmalignant Pain

Mobile Medicard: Pain