字幕列表 影片播放 列印英文字幕 (MUSIC PLAYING) Dr. Stiles: Hello. My name is Dr. Melissa Stiles. I'm with the UW Department of Family Medicine, and I'm joined today by Dr. Jeff Patterson, Professor of Family Medicine, and today we're going to be talking about low back pain and focusing on evaluation. Welcome, Jeff. Dr. Patterson: Thank you. It's great to be here. Dr. Stiles: One of the most common complaints to the primary care office is low back pain, how do you approach this issue? Dr. Patterson: Well, you're right, it is, and of course, there are two areas. One is acute low back pain, which is not so bad when you see it on your schedule and the other is chronic low back pain which gives you a pain in the back when you see it on your schedule. And so we can talk about both of those issues. The second one probably is the more difficult to deal with, actually. The first thing is, seeing an acute low back pain, I think one needs to be careful to rule out any bad things that might be there, and that's done pretty quickly with your history and physical. And I would say that the history and physical in both acute and chronic low back pain are probably the most important features of diagnosing and treating a low back problem. With the acute low back pain, I think the things that we want to make sure are not there are any neurological problems that might indicate a herniated disc, might indicate cauda equina syndrome or advanced cancer or something like that, and again, that can be done fairly quickly in your examination. And once you've done that, infection probably would be the other issue that, again, history would give you an indication about. Once you've done that, then you really have time and can you buy time in terms of your treatment and working with the patient to get them through this acute episode of their low back pain. The chronic low back pain is another story, and generally, those people have been through all kinds of treatment and diagnostic things, and so that becomes a bigger dilemma. Dr. Stiles: What do you need to consideration in the differential diagnosis which is very broad? Dr. Patterson: Sure. So I think the most common things coming from the most common, just strain and sprain, and again what those mean is an interesting question. The person leans over or they've done some activity and their back tightens up and they can't straighten up, can't move, and so that's probably again the most common thing that happens. If we look beyond that, obviously we need to worry about herniated discs and the nerve compromise that might occur with that. We need to worry about cancer, metastatic cancer, and certainly if there is a history of cancer, one needs to have a heightened awareness of that. Infection would be another thing that is really pretty rare in the spine area unless there's been some intervention that's been done maybe somewhere else in the body but certainly can occur that way. Then arthritis and typically osteoarthritis is probably the most common, degenerative arthritis, which is similar to that, and things like spondylolisthesis and spondylolysis, but now we move into the area in what really causes the pain, the back pain. And again, with acute problems, the most common thing is just going to be, quote, lumbar strain and sprain. Dr. Stiles: You touched on some of what I term, the red flags, things that you need to really ask in the history, can you expand on that? Dr. Patterson: Sure. So I think in your history finding out how this started and what happened. If you have a history of a lifting injury, trauma, mild trauma of some sort, then I think you can be fairly reassured that you may not need an urgent MRI or X rays. If there has been more acute trauma than that then certainly we want to think about getting X rays, think being a fracture, compression fracture, or other type of injury like that. Obviously, signs of infection, talking about fever, chills, and probably recent infection elsewhere in the body because certainly I've seen infections spread into the spinal column where the abscesses that form there secondary to infections elsewhere, but that's not real common. And then in the history asking about neurological symptoms, do you have weakness, numbness, tingling, but realizing that weakness, numbness and tingling can all occur just from the sprain and strain, and the weakness most frequently is what I call just pain weakness. It hurts and so I can't do these things, and it's hard for patients to differentiate is this true weakness versus is this pain weakness. But I think those, and then any history of cancer, of course, would heighten my suspicion that I might need to get a scan sooner rather than later here, thinking of metastatic disease. But most of the time, with the history, and sort of the nature of the pain, you can get a pretty good idea of how quickly you need to move with those things. Dr. Stiles: What do you focus on in the physical exam? Dr. Patterson: The physical exam, I think, always should be careful, it should be methodical, and it should be on a bare back. And I think without looking at people's backs, how the back moves, how it feels with palpation, you really don't know much about what's going on. So I think the focus should be on examination, just eye balling the patient's back, and I do that, I have them put a gown on, then I look at their spine, is the spine straight, look for any asymmetry and muscles, I look for asymmetry in pelvic heights, do they have a short leg either because of spasm or because of a true short leg, and do other tests to confirm that. And then range of motion of the back is very important. And not just how far can you bend, because you can have a totally normal range of motion, but very abnormal mechanics in the spine, so get used to looking at that spine with forward bending, with side bending, and rotation to see how it moves. People can't fake that. And you'll see remarkable restrictions in motion in people with back pain. And that's an objective finding in terms of back pain. You'll see, for example, I think side bending is probably the most accurate one. You'll see the spine in the lumbar area not bend at all to the side and people compensate with shoulder motion, perhaps hip motion, they may bend a leg, and then to the other side the spine has a normal curve. And again, that's an objective finding, people can't fake that, and you can document it from one visit to another. The next thing is ruling out a neurological deficits, and this is fairly quick. I just have people rise up on their tip toes, rise up on their heels, and when they rise up on their heels, I watch the dorsal flexion of the big toe, extensor hallucis longus, dorsal flexion of the foot, anterior tibialis and then we rule out one nerve root right then, and then check the reflexes, patellar and achilles reflexes, sometimes that can be difficult to get. I don't worry too much about subtle differences in those, but are they there or not is the thing. And then I often recheck the dorsal flexion of the foot and dorsal flexion of the toe thinking about the nerve roots the patellar, L3, 4, the achilles, L5, S1, and sometimes students have difficulty remembering the levels, and I always say, what does the achilles tendon look like and put my finger up which is like a 1. Okay. And the achilles tendon looks like a 1, and that's an easy way to remember that's L5, S1, and dorsal flexion of the foot, and of big toe, two separate motions, which is L4, 5. Then the rest of the exam, can you do straight leg raising, you can do hip flexion and see what that looks like. Straight leg raising, I think, is probably one of the most overrated tests, and I don't routinely do it, quite frankly. I do hip motion to see if that might be a restricting factor. I also check knees and ankles because there could be other joints that are involved in this. Then palpating the back, turning the patient on their stomach, having them tell you where the pain is, and then careful palpation of the muscles, of the bones, of the ligaments in the area. And I've really come to believe that much of both acute and chronic back pain has ligamentous involved in it, and so careful palpation of the ligaments that are involved gives you probably one of the most beneficial clues to what's going on. Dr. Stiles: When do you consider imaging? Dr. Patterson: So imaging is an interesting question, and frankly, with both acute and chronic pain, in acute pain if there were a neurological deficit, if somebody were having quite severe pain down one leg, then I probably would think about acute imaging that would be X rays to begin with, but probably an MRI is going to be the definitive test here if you're think being a diss, a herniated disc or cancer cause. In chronic pain, most people have had imaging and so I'll try to get those and look at those, and I'll not really anxious in most chronic pain to repeat those things. Many people have had more than one MRI or CAT scan, and frankly, it's just not necessary. Imaging is, probably in the treatment of back pain, one of the most overrated diagnostic things simply because it leads us down the path of what I call reductionist or partialist medicine. And that is, we see a bulging disc or even a herniated disc on the X ray or on the MRI, and it really isn't the cause of the pain and that's quite frequently the case. It leads, I think, to excessive surgery because we see that thing on the X ray, and boy, that's the cause of your pain, and I know we've all seen cases in our practices where after surgery the patient has the same pain or worse pain, and so I think careful palpatory observational diagnosis is probably the most important feature. Dr. Stiles: And where can people go for additional resources on back pain? Dr. Patterson: You know, I think the Academy of Family Medicine has information in terms of the ligamentous causes of pain. I would look to literature on prolotherapy and looking at anatomy and courses that might be involved with that. And I think, again, for chronic back pain, ligamentous involvement probably is the most common cause of chronic low back pain. Dr. Stiles: Great. Thank you very much. Dr. Patterson: Thank you.