System - II. Limb Pain, Lower back pain

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1 Common Problem of the Musculoskeletal System - II Limb Pain, Lower back pain 本講義表格資料取自 Dains, J.E., Baumann, L.C., & Scheibel, P. (2007). Advanced assessment and clinical diagnosis in primary care. (3rd ed). St. Louis: Mosby. 1 圖片取自 Seidel HM, Ball JW, Dains JE, Benedict GW. (1999). Mosby s guide to physical examination. St. Louis, MO: Mosby.

2 Acute Low Back Pain 2

3 Acute lower back pain Actively intolerance producing lower back or back-related leg symptoms of fless than 3 months duration Most common cause Musculoskeletal injuries Age-related degenerative process 90% resolved within 4 weeks without serious sequelae 3

4 AHRQ s causes of ALBP Potentially serious conditions Spinal fracture, tumor or infection, cauda equina syndrom Nerve root compression Sciatic or leg pain and numbness of the lateral thigh, leg, and foot (nerve root compression) Nonspecific back problems Musculoskeletal strain, dickogenic pain, bony deformity 2ndary to inflammatory disease Nonspinal causes secondary to abdominal involvement Psychological causes (Agency for Healthcare Research and Quality) 4

5 Testing for lumber nerve root compromise 5

6 DIFFERENTIAL DIAGNOSIS OF Common Causes of Acute Low Back Pain CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES Potentially Seriou Causes Spinal fracture Trauma to spine or back; pain is felt near site of injury Palpable tenderness over site of fracture Considered an emergency; immobilize patient and transport for radiographs Tumor History of cancer; Weight loss, fever, ESR; bone scan progressive pain is unremitting; occurs at night and at rest tenderness near tumor Osteoblastoma Neck or back pain not Localized tenderness; Plain film shows an relieved by aspirin; occurs in older adolescents and young adults may have scoliosis with muscle pain expansive osteolytic lesion surrounded by thin peripheral rim of bone; bone scan; CT scan Osteoid osteoma Occurs primarily in adolescents; rare in patients over age 40; well localized pain that may be more severe at night and relieved by aspirin or other prostaglandin inhibitors Painful, welllocalized scoliosis may be present Bone scan 6

7 DIFFERENTIAL DIAGNOSIS OF Common Causes of Acute Low Back Pain CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES Potentially Seriou Causes Infection (vertebral osteomyelitis) Diskitis History of infection, invasive i procedure; continuous, dull back pain; chronic back pain Pain aggravated by movement; more common in children Acute onset presents with fever, diaphoresis; i tenderness over affected disk; positive SLR(straight leg raising) Tenderness overaffected disk ESR; blood culture; bone biopsy; CT scan; MRI ESR Cauda equina syndrome Constant pain in a saddle distribution; urinary retention, fecal incontinence, radiculopathy Positive SLR, abnormal DTRs, motor weakness Surgical emergency Sciatica Problems Sciatica Acute back pain with Paravertebral EMG if chronic radiculopathy; history of tenderness and spasm; strain or trauma, relief positive SLR; sitting with sitting knee extension < 60 produce radicular pain below the knee, sensory findings 7

8 DIFFERENTIAL DIAGNOSIS OF Common Causes of Acute Low Back Pain-cont d CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES Nonspecific Back Problems Musculoskeletal strain Spondylolisthesis ( 脊椎炎 ) Ankylosing ( 關節粘連 )spondylitis Spinal stenosis Scheuermann s disease Osteoporosis Pain in back, buttocks; history of new activity or exertion; relief of pain with sitting Young person in a sport that demands rapid movement between hyperflexion and hyperextension or requires excess loading in hyperextension Persons under age 40: insidious onset; progressive morning back pain relieved with exercise Pain worse throughout day; aggravated by standing, relieved by rest; pseudoclaudication Affects mostly adolescent males; mild to moderately severe pain, worse at end of day, relieved by rest Chronic, poorly localized back pain; postmenopausal; slight build; history of inactivity or endocrine disorder Paravertebral tenderness, scoliosis, or loss of lumbar lordosis; no neurological signs No neurological signs; pain localized to low back, just below level of iliac crest; tight hamstrings Painful sacroiliac joints, reduced spine mobility; may have uveitis Signs of osteoarthritis of joints; may have neurological signs Normal examination; may show an exaggerated thoracic kyphosis that is fixed in attempted hyperextension Palpable tenderness over area of compression fracture; kyphosis or lordosis; loss of height None Lumbar spine radiographs ESR; spinal radiographs Spinal radiographs Thoracic spine radiographs Bone densiometry; spinal radiograph to assess fracture 8

9 DIFFERENTIAL DIAGNOSIS OF Common Causes of Acute Low Back Pain-cont d CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES Nonspinal Causes Aortic aneurysm Severe, acute-onset pain not related to activity or movement; increase risk in persons over age 30; pallor, diaphoresis, anxiety, confusion Intact aneurysm will be a visible pulsatile midline upper quadrant abdominal mass; in a dissected aneurysm, upper extremity pulse and pulse pressures are asymmetrical; posterior thoracic pain may be felt Emergency surgical referral Gallstones Increased incidence with age; steady, intense pain in RUQ with radiation to right scapula or shoulder; belching, bloating, fatty food intolerance Normal physical examination or positive Murphy s sign on palpation of abdomen Surgical referral Pyelonephritis Ill-appearing; sweating, nausea, back or flank pain, headache Fever: cloudy, malodorous urine; CVA tenderness on percussion Urinalysis; urine culture Pleuritis History of recent URI; pleuritic pain Normal examination or crackles and bronchial breath sounds PPD; chest radiograph Psychological back pain Psychological back pain History of psychosocial stressors, depression, exaggerated expressions of pain Exaggerated or inconsistent reactions to testing; normal examination None 9

10 Focused History Is This a Potentially Serious Cause of ALBP? Do you have a fever? Have you experienced any trauma to the spine or back? Do you have any other health problems? Have you been treated for cancer?? What is your age? Have you had loss of control of your bowels or bladder? Are you taking any medications? Fever indicating i inflammatory condition i Injury to the back usually cause contusions and abrasions but also can cause spinal fracture Loss of urinary or stool continence indicates cauda equina or S1-S2 nerve compromise secondary to herniated disk. 10

11 Focused History What Does the Location of Pain Tell Me? Where does it hurt? Siatic pain is a sharp, burning pain that radiates down the posterior and lateral leg to the foot or ankle. Back pain with neck stiffness can indicate cervical osteomyelitis. Rheumatoid arthritis produced pain in the upper back and neck Localized pain is seen with spondylolysis and tumors. Flank pain in adults may indicate a kidney infection. Pain of gallbladder disease radiates to the subcapular area. Compression fracture of vetebrae associated with osteoporosis or malignancy may produce pain over midthoracic area 11

12 Focused History What Does the Pattern of Pain Tell Me? When did the pain start? How long have you had this pain? What does the pain feel like? Does it interfere with sleep? Have you had this pain before? The onset of ALBP is sudden, and more than half of patients with this symptom do not associate it with a specific precipitating event or injury. Subacute back pain is 6~12 week duration. Chronic back pain is pain more than 3 months duration Night pain is a worrisome symptom that often signals a serious such as tumor, infection, or inflammation. M i tiff th t i th d t k l i Morning stiffness that improves as the day progresses suggests ankylosing spondylitis. 12

13 Focused History What Does the Pain in Relation to Activity Tell Me? What makes the pain worse?? What makes the pain better? Pain that t is aggravated by activity it and alleviates by rest is usually muscuoskeletal in origin. Spinal stenosis is associated with increased pain with standing, sneezing, or coughing, and is relieved on flexion of the spine.. Pain experienced in the lumber area occurring after strenuous sporting activities is usually the result of trauma to muscles and tendons, causing contusion and sprain. Suspect spondylolisthesis, or forward slippage of one vetebra over another, if the onset of pain is during hyperextension. Back pain not associated a with any activity and not relieved eved by rest may indicate tumor. 13

14 Focused History What Does Rediation of Pain Tell Me? Does the pain travel? Show me Where the pain travel? Pain from the upper lumber spine usually radiates to the anterior aspect of the thigh and leg. Pain from the lower lumber spine usually radiates to the gluteal region, posterior thigh, and calves. Pain from visceral disease is usually felt within the abdomen and flank. Gallbladder pain radiates around the trunk to right scapula. Person with spondylolysis complain of hamstring tightness and buttack discomfort as well as low back pain. Siatic pain: sharp, burning radiates down to the lateral or posterior aspect of the leg to the lateral ankle or foot 14

15 Focused History Are There Signs of Neurological Damage? Have you been stumbling?? Have you noticed any change in your balance or coordination? Does the child frequently stumble or fall? Do you have numbness or tingling g in your extremities?? Is There a Family History of Back Pain? Does anyone in your family have scoliosis or a crooked spine? Could This Pain Be Caused by a Systemic Disease?: Have you been ill? eg, PID, URI, 15

16 Focused PE Observe the Patient,s General Appearance Observe Gait Assess Vital Sign Examine Skin Examine Eyes, Ears, Nose, and mouth Inspect the Back and Extremities Percuss and Palpate Back and Spine Perform Range of Motion of the Spine Perform Straight Leg Raising Check Hip Mobility Examine Feet Evaluate Muscle Strength Measure Muscle Circumference Test Sensory function Assess Deep Tendon Reflexes Palpate the Abdomen Check Rectal Sphincter Tone 16

17 Lab and diagnostic studies Plain Radiographs Standing Anteroposterior and Lateral Views of the Spine Oblique and Flexion Views of the Spine Spine Radiograph Bone Scan Electromyography Diagnostic Imaging Urinalysis Erythrocyte Sedimentation Rate Complete Blood Cell Count 17

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Epidemiology of Low back pain

Epidemiology of Low back pain Low Back Pain Definition Pain felt in your lower back may come from the spine, muscles, nerves, or other structures in that region. It may also radiate from other areas like the mid or upper back, a inguinal