SIU School of Medicine

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Department of Internal Medicine

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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