Channel: nabil ebraheim

Category: Education

Tags: treatmentorthopaedicsdr. nabil ebraheimutmclow back paindiagnosisosteoporosisfracturemyelopathysymptomsnathan elkinssignscomplicatedmanagmentconditionsanklyosing spondilitisut

Description: Dr. Ebraheim’s educational animated video describes the condition of low back pain complicated associated conditions. Follow me on twitter: twitter.com/#!/DrEbraheim_UTMC Find me on Instagram @OrthoInitiative Low Back Pain Could Be Complicated youtube.com/watch?v=S8so3aeY0Ic&t=1s Low back pain could be complicated You will find no cause for low back pain in about 85% of patients. Usually the pain will go away and it 95% of the patients their pain will resolve in about 3 months. In some patients, the pain may be multifactorial or nonorganic. The pain also may be referred from other areas such as the hip joint, the buttocks, or the sacroiliac joint. The MRI may give us false positives, so study the images carefully! Correlate the images with the patient's history and physical examination. The patient may have red flags that require further investigation such as significant trauma, previous malignancy, severe progressive neurological deficit, loss of bladder and bowel control, or the patient may have systemic component such as fever, chills, or weight loss. The pain may also be referred from aortic aneurysm, renal stones, pancreatitis, pelvic diseases, duodenal ulcer, or acute myocardial infarction. Let us exclude all the situations and we ended by low back pain that originates from the spine itself, but it is not the simple one, it is complicated! What are the scenarios? 1. Cauda equina syndrome a. The patient will have more leg pain than back pain, but also bladder and bowel problems, incontinence, frequency, perianal numbness (these could be missed in the outcome could be catastrophic). When you see the patient, asked the patient if they have bladder or bowel symptoms and if they do, then you need to do an emergency MRI and urgent surgery. This provides the best chance for resolution of the symptoms, especially the bladder. 2. Patient has back pain with progressive neurologic deficit. a. Study why the patient has neurologic deficit! If you cannot find the cause in the lower back, then look for it in the thoracic spine rather than neck (get MRIs). If the patient has a pacemaker, then get a myelogram with CT. 3. The patient has low back pain and gait disturbance. a. Get an MRI of the cervical spine! Look for concomitant cervical myelopathy due to compression of the spinal cord. Careful patient selection is the key for successful outcome, especially in patients with nonspecific low back pain. Back pain is the most common Workmen's Compensation claim in the United States, accounting for 25% of all claims, and one third of all total compensation cost. 4. Worker's Compensation is an independent risk factor for unsatisfactory outcome after surgical procedure. a. Worker's Compensation patients that are treated surgically have a poorer outcome than the general population. 5. The patient has a history of cigarette smoking. a. Smoking affects the disc nutrition and also affects the healing of the fusion. 6. Patient has low back pain and ankylosing spondylitis. a. This patient sometimes has an occult fracture (you can see it) and have a higher rate of neurodeficit and a higher mortality rate after surgery. You need to get an MRI or CT scan if there is significant back pain to see if there is an undiagnosed fracture, and this patient probably will need surgery if there is a fracture. 7. Patient has low back pain and an osteoporotic fracture. a. Get DEXA scan. Provide medical treatment. In an acute fracture, you may want to give the patient a brace or surgery. If you have an older patient with a lot of pain, then get an x-ray, because you may find an osteoporotic compression fracture. 8. Patient has low back pain and depression. a. Depression has a negative effect on the outcome after surgery. 9. Patient will need anticoagulation after surgery. a. There is a risk-benefit and the filter may be useful in that situation. 10. The patient has neurogenic claudication (low back pain with heaviness and cramps of the calves) and sitting relieves the pain, then the patient probably has lumbar stenosis. Get an MRI, it will show you the problem and the patient would benefit from surgery on the spine. a. This neurogenic claudication is pain and heaviness in 1 or both legs. The pain increases with an upright position and is relieved by sitting down or leaning forward. This situation is worse if you have associated vascular claudication. Patient will need vascular consult and maybe vascular surgery.