Morning Report

1
Morning Report

• 7/7/1999
• Victor Ghobrial, MD
• William Fink, MD

2
HPI

• 91 F presented to the hospital with 2 days Hx of
  cough, scanty yellowish sputum production and
  elevated temp.
• Also C/O low back pain which has been going on
  for the past three years but has been worse
  lately.
• She denied CP, N/V or other symptoms.

3
PMH

• HTN
• DJD
• No DM, CAD or cancer

4
HP

• NKDA
• Tylenol daily
• SH No smoking or alcohol abuse
• Family Hx non- contributory

5
Physical Exam

• Elderly female in no distress
• T 102 BP 160/80 P 94 RR 24 Pox 97 RA
• HEENT PERRBL, No ear or nose D/C
• Neck Supple without JVD
• Ht RRR S1 S2 audible without murmurs
• Lungs Bibasilar crackles no wheezes or rhonchi

6
HP

• Abdomen Soft not tender with positive BS and
  without organomegally
• Ex No E, C, C. 1 PP
• Neuro Disoriented to time. No focal deficits or
  CN palsies

7
Labs

• Na K Co2 Cl BUN Cr
  
  142 3.2 22
  100 9 0.6
• Glucose
  
  120
• CXR

8
Hospital Course

• Pt was admitted for 3 days, treated with Abx for
  community acquired pneumonia
• Back pain continued and spinal films revealed
  compression fx of lumbar vertebrae with Rt
  scoliosis
• Pt was prescribed vit D with Ca and percocet PRN

9
Low Back Pain

• Structure of the back vertebrae and discs are
  supported by ligaments and paravertebral ms,
  discs consist of gelatinous nucleus pulposus and
  surrounding annulus fibrosus
• Sinovertebral n. arises from corresponding spinal
  n. and carries sensation

10
Etiology

• Trauma bone, joints or ligaments
• Mechanical pregnancy, obesity or scoliosis
• Degenerative osteoarthritis
• Infections osteomyelitis, TB, meningitis
• Metabolic osteoporosis, osteomalicia
  
  

11
Etiology

• Neoplastic myeloma, Hodgkins, pancreatic Ca,
  breast mets, prostate, lung
• GI ulcers, pancreatitis, cholelithiasis, IBD
• Renal hydronephrosis, calculus, neoplasm, renal
  infarcts, pyelo-nephritis
• Hematological sickle cell crisis, hemolysis

12
Etiology

• Vascular leaking aortic anurysm, subarachnoid
  or spinal he
• Gynecologic tumors of uterus, ovary,
  dysmenorrhea, uterine prolapse
• Inflammatory ankylosing spondylitis, arthritis,
  Reiters syndrome, strain
• Psycogenic malinger, anxiety, hysteria

13
evaluation

• Differentiate between two main types
  
  Mechanical xxx Medical
• Most of the time it is self-limited about 50
  will improve in 1st week, 51-86 in 1st month and
  92 in 2 months
• Identify pts with Cancer, Infection, Neuro
  deficits, Inflammatory dis Leaking AAA

14
exam

• Standing Position
• 1- Kyphosis, lordosis and scoliosis
• 2- Localize tenderness
• 3- Schober test 10cm line at LSJ above should
  extend gt 15cm

• Sitting Supine
• 1- Reflexes Knee(L4) Ankle(S1)
• 2- SLR if elevated 60or less, spes 40, sens
  95.
• 3- Crossed Straight Leg 9025

15
labs

• CBC ESR InflammatoryNeoplastic
• Ca Alka phos Diffuse bone disease
• Serum Urine Electrophoresis MM
• Acid phos PSA Prostate Ca
• UA Renal disease
• Occult Stool GI diseases

16
X-Ray

• Not necessary for initial work up unless hx of
  trauma, infection, malignancy or inflamm
• By age 50, 67 of normal population have evidence
  of disc disease and 2/3 of pts who have evidence
  of lumbar disc degeneration are asymptomatic
• Should be reserved for persistant pain,
  tenderness, elderly and if Rx fails

17
MRI

• Highly diagnostic
• Reserved for pts in whom information will change
  Rx
• Needed urgently if suspecting Cauda equina or
  Epidural mass
• Not needed in disc herniation

18
Scans

• CT if used instead of MRI must be with
  intrathecal contrast to yield high resolution
• Radionuclide Bone Scanning has limited utility,
  useful in osteomyelitis or mets.
  It
  is normal in MM (lytic lesion)

19
Drug Rx

• 1st line NSAIDs for analgesia if failed narcotics
  usually not longer than 2 weeks
• Muscle relaxants of no proven value but if needed
  should be used for no longer than 2 weeks
• Corticosteroid injection of unknown value

20
rest exersices

• Once thought as cornerstone of therapy, now are
  ineffective for acute pain
• 2 days of bed rest gives better results than 7
  days
• The value of traction and corsets is doubtful
• Early mobilization is the current trend

21
Surgery

• Needed urgently if evidence of evolving
  neurologic deficits, consistent pain syndrome
  that failed conservative Rx for 46 weeks
• Percutaneous lumbar discectomy is safe and
  effective (75) alternative to laminectomy