Wednesday, September 24, 2008

Day 85 - "That sounds bad"

Back pain is one of the most frequent complaints in medicine. Today's case highlighted why it always needs to be taken seriously.

Back Pain:

  • Mechanical: Classically worsens with movement, better with rest. Can be referred down to bilateral hips, thighs.
    • Patterns:
      • Radiculopathy (classically sciatica): pain radiates in dermatome of nerve root impingement. May be associated with neurologic symptoms (weakness or numbness) in the affected area
      • Spinal Stenosis: pain radiates to legs. Worse with activity. Predictably improves with leaning forward, rest
    • RED FLAGS:
      • Night pain
      • B-Symptoms (fever, sweats, weight loss)
      • Neurological symptoms including numbness, weakness, bladder incontinence (overflow), fecal incontinence (loss of sphincter tone)
      • Known history of malignancy
  • Inflammatory: associated with morning stiffness, aggravated by rest, possibly extra-axial symptoms of connective tissue disease.
  • Referred pain
The examination should include a general exam looking for signs of systemic disease. A focussed exam should look for focal bony or paraspinal tenderness, and neurological findings (including rectal tone if appropriate), and associated MSK findings.




In the case today the patient had progressive, severe back pain in the context of 2 months of B-symptoms. He presented with cord compression.

Differential:
  • Malignancy:
    • Most commonly prostate, breast, lung. Then RCC, lymphoma and myeloma
    • Pain (present in 95%) is often the first symptom, usually preceeding neurologic symptoms by several weeks
    • Weakness (up to 85%) and sensory losses follow. Can also have bowel/bladder dysfunction and gait ataxia.
    • Patients should get steroids (dexamethasone 10mg IV x 1 then 16mg/day in divided doses tapered over 2 weeks), intravenous pamidronate, and either neurosurgery or radiation.
    • This trial showed that for metastatic disease in a single area, surgery +RT was superior to RT alone for solid tumors.
  • Infection:
  • Other:
    • Traumatic, vertebral compression fracture
Diagnosis is best made with MRI. If MRI is not an option, the next best test would be a CT myelogram.

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