Discuss the management of a patient who presents with lower back pain.

FROM AN ARNP PERSPECTIVE.Discuss the management of a patient who presents with ACUTE lower back pain. Explain why this may be an emergent situation and how you would proceed in the management of this patient. Include any differential diagnoses, diagnostic studies, and other treatment measures for this patient. Include when you would refer this patient to another health care provider.

• You are the provider, so in addition to knowing disease process and management, patient will also look to you for what to do. What additional questions should you ask the patient and why?
• Explain why this may be an emergent situation and how you would proceed in the management of this patient
• What should be included in the physical examination at this visit?
• What are the possible differential diagnoses at this time?
• What diagnostic studies tests should you order and why?
• How should this patient be managed AND other treatment measures for this patient.
• when you would refer this patient to another health care provider?

Students are expected to:

1. Post an initial substantive response of to each questions as an FNP. Use Diagnostic Reasoning to answer each question.
2. Please be sure to validate your opinions and ideas with in text citations and references in APA format.
3. References and citations should conform to the APA 6th edition.
4. Substantive comments add to the discussion and provide your fellow students with information that will enhance the learning environment.
5. The peer postings should be at least one paragraph (approximately100 words)

Jaime’s Response:

Low Back Pain

Low back pain can be caused by actions as simple as sneezing and cough. It is imperative the provider screen patients for severe emergent situations that require evaluation by a neurosurgeon. Thus, when evaluating low back pain and predicting injury, it is not accurate to gauge the precipitating event in predicting the injury.

Emergent Situations

A physical exam such as a straight leg raise, or contralateral straight leg raise may indicate a common problem such as, a herniated nucleus pulposus (HNP). The femoral stretch or contralateral femoral stretch, when positive indicates a HNP in the lumbar spine. The Gaenslen Test, which is the application of pelvic compression, when positive will indicate sacroiliacitis. The FABER test is also positive in sacroiliacitis (“Epocrates,” 2018).

Urgent work-ups are required when tumors, infection, trauma, or the presence of caudina equine syndrome is suspected. Patients that are at the highest risk for infection or tumor, are those on immunosuppressive therapy, and IV drug users. These pt will present with unresolved pain, chills, weight loss and profound neurologic deficits. Patients with caudia equina syndrome present with bowel or bladder dysfunction, bilateral sciatica, and saddle anesthesia. All of the aforementioned findings immediate radiological testing, such as MRI.

Differential Diagnosis

1. Lumbar Muscle Strain: muscle spasms are present, but an otherwise benign exam. Pain may continue to 3months. May prescribe muscle relaxers, ice/heat, pain meds, physical therapy.

2. HNP: positive straight leg-raise or femoral stretch test. Order MRI, refer to surgeon when all nonsurgical modalities have proven ineffective.

3.Spinal stenosis: intermittent pain in the legs or thighs that is worse with sitting standing and walking. Pt’s are noted to walk with a forward flexed gait. Pt’s may c/o numbness, heaviness, with unilateral or bilateral radicular pain, motor deficits, bowel or bladder dysfunction, back and but pain with standing and ambulation. An MRI is warranted with these symptoms.

4.Compression Fracture: typically, history of trauma, although some events may not be eventful. Plain films are the first choice of testing.

5. DJD: worse symptoms with flexion, coughing/sneezing, heavy lifting. Plain films may reveal arthritis or diffuse osteophyte formation.

6. Sacroilitis: tenderness at SI joint. Perform x-rays, which should be negative.

7.Referred Pain: AAA, Pancreatitis, Pyelonephritis, kidney stone, peptic ulcer disease.

8. Other illness: osteomyelitis, malignancy, inflammatory spondyloarthropathy, connective tissue disease, spondylolysis(“Epocrates,” 2018).

References

Atlas, S. J. (2018). Evaluation of low back pain. Retrieved 16Nvo 2018, from https://www.uptodate.com/contents/evaluation-of-lo…

Evaluation of back pain. (2018). Retrieved from https://online.epocrates.com/diseases/18922/Evalua…

April’s Response:

Prevalence of Low Back Pain

Low back pain is a common complaint encountered in the primary care setting, accounting for approximately 1.3% of visits. In fact, it is estimated that up to 84% of individuals will experience low back pain during their lifetime (Wheeler et al., 2018).

Non-emergent Causes of Low Back Pain

The vast majority of patients, up to 85%, will present with non-specific low back pain, meaning that no specific underlying condition will be identified to explain the pain. Non-emergent specific causes of low back pain include the differential diagnoses of vertebral compression fracture, radiculopathy, spinal stenosis, piriformis syndrome, ankylosing spondylitis, osteoarthritis, scoliosis, and sacroiliac joint dysfunction (Wheeler et al., 2018).

Emergent Causes of Low Back Pain

Approximately one in ten individuals with low back pain will present with an emergent situation. There are five emergent pathologies that should be ruled out when considering patients with low back pain including infection, fracture, disc herniation with cord compression, spinal metastasis with cord compression, and vascular catastrophe (Helman, 2017). Some red flag symptoms that place a patient at higher risk for one of these emergency causes include fever and neurological deficits such as urinary retention, urinary incontinence, new fecal incontinence, saddle anesthesia, and significant motor deficits that cannot be localized to a single unilateral nerve root (Wheeler et al., 2018).

Diagnostic Testing

In cases of suspected emergency causes of low back pain, timely imagining is important. MRI is the advanced imaging of choice when considering disc issues, spinal cord and nerve involvement, spinal infection, and malignancy. CT scan may indicated in those who cannot undergo MRI testing. Plain radiographs of the lumbar spine can be adequate at detecting fractures (Wheeler et al., 2018).

Treatment and Referral

If the MRI shows an emergent finding as described above, the patient should be referred to the proper specialist, be it an orthopedic surgeon, neuro surgeon, or infectious disease specialist. In patients who present with non-specific low back pain, conservative management is often indicated including NSAIDs, muscle relaxants, physical therapy, heat, massage, and oral steroids to decrease inflammation (Hauk, 2017). Patients should be rechecked if they have not improved in four to six weeks of conservative treatment. Referral should be considered for those who have not improved after 12 weeks total, as further evaluation and treatment may be indicated (Wheeler et al., 2018).

References

Hauk, L. (2017). Low back pain: American College of Physican’s Practice Guideline on Noninvasive Treatments. American Family Physician, 96, 407-408.

Helman, A. (2017, January 11). Low Back Pain Emergencies Could Signal Neurological Injuries. Retrieved from https://www.acepnow.com/article/low-back-pain-emergencies-signal-neurological-injuries/3/?singlepage=1

Wheeler, S. G., Wipf, J. E., Staiger, T. O., Deyo, R. A., & Jarvik, J. G. (2018, July 12). Evaluation of low back pain in adults. Retrieved from https://www.uptodate.com/contents/evaluation-of-low-back-pain-in-adults