Back Pain

BACK PAIN

Rationale

Back pain is one of the most commonly encountered problems in the outpatient primary care internal medicine setting. It has an important differential diagnosis, and the initial decision-making must be made on the basis of clinical findings.

Prerequisites

Prior knowledge and skills acquired during the pre-clerkship experience should include:

Knowledge of

the bony, soft tissue, vascular and neuro anatomy of the spine

the dermatomes corresponding to spinal roots

the pathophysiology of osteoarthritis, spinal stenosis, osteoporosis, disc degeneration and the primary origin of spinal metastases

The ability to perform a

physical examination of the spine

neurologic examination of the lower extremities

Knowledge

Students should be able to define, describe and discuss:

the signs and symptoms of:

ligament or muscle strain

back deformities:

kyphosis

scoliosis

lumbar disc herniation

degenerative arthritis

sacroileitis

vertebral compression fracture

spinal metastasis

spinal epidural abscess

spinal stenosis

cauda equina syndrome

the clinical features that differentiate one etiology from another

the physical exam findings that correspond to nerve root compression at the L4, L5, and S1 levels

the role of imaging studies in the evaluation of back pain, including their indications, limitations and cost:

x-ray

MRI

CT

myelogram

EMG/NCS

bone densitometry

the natural history of the important causes of back pain:

especially those which require urgent attention:

cauda equina syndrome

epidural abscess

spinal metastases

those which do not require urgent attention:

mechanical low back pain

minor disc herniation

response to therapy of the various etiologies, with understanding of the roles of:

bed rest

exercise

analgesia

anti-inflammatory agents

heat/cold

ultrasound

back manipulation

surgical interventions

means of limiting disability and chronicity

Skills

Students should demonstrate specific skills, including:

History-Taking Skills: Students should be able to obtain, document, and present a medical history that outlines the key elements helpful in establishing the etiology of back pain and determining degree of disability including:

age

weight loss

fever

prior history of cancer

trauma

sciatica

paraspinal muscle spasm

muscle atrophy

vertebral compression fracture

anatomic abnormalities – scholiosis/kyphosis

sacroileitis

focal numbness or weakness

rapid progression of symptoms

saddle anesthesia

alarm symptoms

unremitting pain (constant at night)

bilateral weakness

bowel/bladder/sexual dysfunction

Physical Exam Skills: Students should be able to perform a physical exam of the back and a neurologic exam that includes:

inspection of movement and gait

palpation of the spine, paraspinous musculature and sciatic notches

straight-leg raising test

assessment for:

radiculopathy

motor strength, sensation and deep tendon reflexes of the lower extremities

spinal cord compression

urinary retention

saddle anesthesia

bilateral neurologic findings

epidural abscess

fever, focal erythema, warmth and tenderness

Differential Diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology of back pain.

Laboratory Interpretation: Laboratory Interpretation: Students should be able to recommend when to order the following laboratory tests and imaging studies and be able to interpret them with consultation:

sedimentation rate

lumbosarcal spine x-rays

CT scan

MRI

bone scan

myelogram

DEXA (bone densitometry)

Electromyogram and Nerve Conduction Studies (EMG)

Management Skills: Students should be able to develop an appropriate evaluation and treatment plan for patients that includes:

proper use of analgesics and muscle relaxants

teaching:

back hygiene measures

proper use of bed rest and exercises

mechanics of lifting and standing

lifestyle modifications – including weight loss

timely use of consultants in properly selected patients

provision of psychological support and patient education

a cost-effective approach based on the differential diagnosis, with parsimonious, but appropriate use of imaging tests

appropriate treatment strategies for patients with chronic low back pain

knowledge of the role of chiropractic or acupuncture intervention

Attitudes and Professional Behaviors: Students should be able to:
- respond appropriately to a patient with chronic back pain
Resources
- Internal Medicine Clerkship Guide, Mosby, 2003 pp160-167 and 515-520.
- Clerkship Seminar, “Low Back Pain,” R.Kovach, MD
- Primer on Rheumatic Diseases, Edition 12, published by Arthritis Foundation, Musculoskeletal signs and symptoms; C. Disorders of the Low Back and Neck; pps 165-170
- 2004 Current Medical Diagnosis and Treatment. pp 788-791
- Jarvik and Deyo. Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging. Ann Int Med, 137(7), 586-597
- Deyo and Weinstein. Low Back Pain. NEJM, 344(5), 363-370
- "Persistent Low Back Pain", Eugene J. Carragee, M.D., N Engl J Med 2005;352:1891-8.

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