Lower Back Pain Diagnosis and Imaging
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What is the primary reason for not performing imaging for lower back pain within the first 6 weeks?

  • To delay treatment and observe the patient's condition
  • To avoid excessive radiation exposure
  • To reduce healthcare costs
  • Unless red flags are present, such as severe or progressive neurologic deficits (correct)

    • What is the recommended initial imaging study for a patient with a concern for a vertebral compression fracture?

  • Bone scan of the lumbar spine
  • CT scan of the lumbar spine
  • Plain lumbar spine x-ray (correct)
  • MRI of the lumbar spine

    • What is the most likely cause of the patient's pain in Case 1?

  • Vertebral compression fracture
  • Lumbar stenosis at L4-L5 and L5-S1 (correct)
  • Right hip problem
  • Facet joint injections

    • What is the most appropriate next step in the management of Case 1?

    <p>Passive examination of the right hip</p> Signup and view all the answers

    What is the primary symptom of the patient in Case 2?

    <p>Pain radiating from the buttock to the right heel</p> Signup and view all the answers

    What is the significance of red flags in the evaluation of lower back pain?

    <p>Presence of severe or progressive neurologic deficits or serious underlying conditions</p> Signup and view all the answers

    What is the purpose of a bone scan in the evaluation of lower back pain?

    <p>To exclude tumors of the spine</p> Signup and view all the answers

    What is the primary reason for referring the patient in Case 1 to a pain specialist?

    <p>To manage the patient's pain with facet joint injections</p> Signup and view all the answers

    Which of the following is the most likely underlying cause of the patient's weakness in her legs?

    <p>Cervical spinal stenosis</p> Signup and view all the answers

    What is the significance of the positive Romberg test in this patient?

    <p>It indicates a sensory ataxia</p> Signup and view all the answers

    Which of the following is the most likely explanation for the patient's difficulty opening jars and buttoning blouses?

    <p>Impaired fine motor skills due to a central nervous system disorder</p> Signup and view all the answers

    What is the most likely explanation for the patient's constipation and urinary urgency?

    <p>Autonomic dysfunction due to a neurodegenerative disorder</p> Signup and view all the answers

    Which of the following is the most appropriate next step in the evaluation of this patient's condition?

    <p>MRI of the cervical spine</p> Signup and view all the answers

    What is the most likely explanation for the patient's gait abnormality?

    <p>Cervical spinal stenosis</p> Signup and view all the answers

    What is the primary cause of peripheral neuropathy in the US?

    <p>Diabetes</p> Signup and view all the answers

    What is the typical presentation of peripheral neuropathy in older adults?

    <p>Gait impairment from sensory and motor deficits, with resulting propensity to fall</p> Signup and view all the answers

    What is the primary diagnostic tool for peripheral neuropathy?

    <p>Electromyography and nerve conduction studies</p> Signup and view all the answers

    What is the treatment of choice for polymyositis?

    <p>Prednisone</p> Signup and view all the answers

    What is the characteristic of motor neuron disease (amyotrophic lateral sclerosis)?

    <p>Progressive, fatal neurodegenerative condition involving both upper and lower motor neuron cell bodies</p> Signup and view all the answers

    What is the primary symptom of radiculopathy?

    <p>Pain radiating down the neck, back, arm, or leg</p> Signup and view all the answers

    What is the treatment of choice for acute inflammatory demyelinating polyradiculoneuropathy?

    <p>Plasma exchange</p> Signup and view all the answers

    What is the primary cause of myelopathy?

    <p>All of the above</p> Signup and view all the answers

    What is the average survival rate for patients with motor neuron disease (amyotrophic lateral sclerosis)?

    <p>2 to 3 years</p> Signup and view all the answers

    What is the primary goal of treatment for peripheral neuropathy?

    <p>To manage symptoms and improve quality of life</p> Signup and view all the answers

    What percentage of patients with Guillain-Barré syndrome have residual weakness after 3 years?

    <p>15%</p> Signup and view all the answers

    What is the primary purpose of the International Guillain-Barré Syndrome Outcome Study (IGOS)?

    <p>To examine outcomes of the disease based on clinical and biological determinants and predictors</p> Signup and view all the answers

    What is the normal function of acetylcholine in the neuromuscular junction?

    <p>To bind to acetylcholine receptors and generate a muscle contraction</p> Signup and view all the answers

    What is the effect of the person's own antibodies in myasthenia gravis?

    <p>They block, alter, or destroy the receptors for acetylcholine</p> Signup and view all the answers

    What is the estimated percentage of people with myasthenia gravis who have auto-antibodies directed at acetylcholine receptor sites?

    <p>80-90%</p> Signup and view all the answers

    What is the estimated percentage of people with myasthenia gravis who have thymus hyperplasia or thymus tumor?

    <p>80%</p> Signup and view all the answers

    What is the primary role of the thymus in myasthenia gravis?

    <p>To produce antibodies against acetylcholine receptors</p> Signup and view all the answers

    What is the initial step in diagnosing myasthenia gravis?

    <p>Start with a detailed history</p> Signup and view all the answers

    What is the most common cause of disability in young adults?

    <p>Multiple Sclerosis</p> Signup and view all the answers

    Which of the following is NOT a symptom of Multiple Sclerosis?

    <p>Seizures</p> Signup and view all the answers

    What is the best fit diagnostic criterion for Multiple Sclerosis?

    <p>Two attacks, two areas of CNS involved</p> Signup and view all the answers

    Which of the following is a disease modifying agent used in Multiple Sclerosis?

    <p>Interferon beta-1a</p> Signup and view all the answers

    What is the pathophysiology of Guillain-Barre Syndrome?

    <p>The immune system attacks the myelin sheath surrounding the axons of peripheral nerves</p> Signup and view all the answers

    Which of the following is a symptom of Guillain-Barre Syndrome?

    <p>Muscle paralysis</p> Signup and view all the answers

    What is the treatment of choice for Guillain-Barre Syndrome?

    <p>Plasmapheresis</p> Signup and view all the answers

    Which of the following is a differential diagnosis for Multiple Sclerosis?

    <p>All of the above</p> Signup and view all the answers

    What is the primary progressive subtype of Multiple Sclerosis?

    <p>Primary Progressive</p> Signup and view all the answers

    What is the purpose of lumbar puncture in the diagnosis of Guillain-Barre Syndrome?

    <p>To monitor CSF protein levels</p> Signup and view all the answers

    Study Notes

    Lower Back Pain

    • Do not perform imaging for lower back pain within the first 6 weeks unless red flags are present (severe or progressive neurologic deficits or serious underlying conditions)
    • If there is a concern for a vertebral compression fracture, a plain lumbar spine x-ray should be done immediately after evaluation

    Peripheral Neuropathy

    • Can be particularly devastating in older adults, causing gait impairment from sensory and motor deficits, leading to a propensity to fall
    • Prevalence up to 10% in older adults, 30%-60% in patients >60 years with diabetes mellitus
    • Common causes:
      • Medications, alcohol abuse, and nutritional deficiencies
      • Renal disease (uremia)
      • Monoclonal gammopathy (e.g., multiple myeloma)
      • Neoplasia
    • Diagnosis:
      • History geared towards identifying possible causes and risk factors
      • Neurologic examination to establish evidence of length-dependent loss of sensory and/or motor function
      • Electromyography and nerve conduction studies to help classify the neuropathy
      • Refer acute, atypical, rapidly progressive, or severe forms of neuropathy to a neurologist with expertise in neuromuscular medicine
    • Treatment:
      • Depends on underlying cause
      • Optimizing glucose control can lessen the severity of diabetic neuropathy
      • Treating neuropathic pain:
        • Tricyclic antidepressants (off-label)
        • Gabapentin or pregabalin (FDA-approved for post-herpetic neuralgia; pregabalin also approved for diabetic neuropathy)
        • Duloxetine (FDA-approved)
        • Tapentadol (FDA-approved)
        • Tramadol and opioids (all off-label) (SOE=B)
        • Topical agents (e.g., capsaicin cream, lidocicine patch) (SOE=B)

    Radiculopathy

    • Cause: compression of spinal root as it exits spinal cord
    • In older adults, may result from:
      • Herniated discs
      • Osteophyte formation
    • Symptoms:
      • Pain may radiate down neck, back, arm, or leg
      • Neurologic examination may reveal:
        • Motor and sensory defects
        • Diminution of reflexes in distribution of spinal root(s)
    • Diagnosis:
      • MRI with contrast and lumbar puncture with cytology may help make the diagnosis
      • Acute inflammatory demyelinating polyradiculoneuropathy (AIDP), also termed Guillain-Barré syndrome, is an acute, immune-mediated form of polyradiculopathy
      • Chronic inflammatory demyelinating polyneuropathy is a chronic form of AIDP and requires long-term immunotherapy
      • Patients with diabetes may present with diabetic amyotrophy, a lumbosacral polyradiculitis and plexopathy

    Myopathy

    • Characterized by proximal muscle weakness, wasting, and diminished or absent reflexes
    • Can be accompanied by increases in muscle enzymes, myopathic pattern on electromyogram, and abnormal muscle biopsy
    • Polymyositis: disorder of skeletal muscle
      • Muscle biopsy shows signs of lymphocytic infiltration, and usually also myocyte degeneration and regeneration
      • Prednisone is the treatment of choice but should be used with caution in older adults
    • Thyroid-related myopathies:
      • Weakness and wasting are greatest in the pelvic girdle muscles and, to some extent, the muscles of the shoulder region
      • Reflexes can be normal, and diagnosis is based on the distribution of muscle weakness
      • Improves with successful treatment of the underlying endocrine disorder, such as hypothyroidism

    Motor Neuron Disease (Amyotrophic Lateral Sclerosis)

    • Progressive, fatal neurodegenerative condition involving both upper and lower motor neuron cell bodies
    • Symptoms:
      • Progressive weakness and wasting of skeletal muscles
      • Often in combination with bulbar palsy and respiratory failure
      • Common symptoms: gait disturbance, falls, foot drop, weakness in grip, dysphagia, dysarthria
    • Electromyography demonstrates findings consistent with diffuse denervation and poor recruitment of motor units
    • Differential diagnosis:
      • Lesions at the level of the foramen magnum
      • Combination of cervical myelopathy associated with cervical and lumbar polyradiculopathies
      • Motor-predominant peripheral polyneuropathy
    • Average survival 2-3 years, with the presence of bulbar weakness carrying a poorer prognosis
    • Treatment is mostly supportive, with riluzole having modest effects on survival, time to tracheostomy (SOE=A)

    Myelopathy (Spinal Cord Dysfunction)

    • Intrinsic lesions can result from spinal cord tumors, vascular events (infarcts or hemorrhages), or trauma
    • Extrinsic lesions are more prevalent, such as:
      • Cervical spondylosis
      • Disc prolapse or herniation
      • Vertebral body subluxation due to rheumatoid arthritis
      • Meningioma or spinal metastases
    • MRI can be helpful for diagnosis, but abnormal findings are common in older adults
    • Decompressive surgery is recommended for persistent pain or progressive neurologic deficit

    Multiple Sclerosis

    • Most common cause of disability in young adults

    • Recurrent, occasionally progressive, inflammatory demyelination of white matter of brain and spinal cord

    • Multiple varied neuro symptoms and signs

    • Autoimmune attack on myelin: brain and spinal cord

    • Cause unknown

    • Genetic susceptibility

    • Human herpes virus 6

    • Latent infection in CNS

    • Vitamin D Deficiency

    • Symptoms:

      • Unilateral vision loss
      • Diplopia (days to weeks)
      • Hemiparesis (slow insidious)
      • Fatigue, mobility, cognitive dysfunction, bowel and bladder, depression and mood disorders

    • Diagnosis:

      • History
      • MRI [supports the diagnosis]
      • Cerebral spinal fluid

    • Differential diagnoses:

      • Acute disseminated encephalomyelitis
      • Syringomyelopathy
      • Foramen magnum lesion
      • Progressive multifocal leukoencephalopathy
      • Pernicious anemia
      • Spinal cord tumor
      • Vasculitis
      • CNS infections
      • Neuro syphilis
      • Lyme disease
      • Hereditary ataxia

    • Diagnostic criteria:

      • Two attacks, two areas of CNS involved
      • Neuro signs at least two separate areas of involvement
      • Best fit

    • Subtypes:

      • Relapsing Remitting (RR)
      • Secondary progressive (SP)
      • Progressive relapsing (PR)
      • Primary progressive (PP)

    • Management:

      • Disabling symptoms
      • Acute attacks—therapies to reduce inflammation and shorten duration
      • Long-term treatment
        • Five therapies approved
        • Reduce attacks
        • Prevent new lesions in brain
        • Slow disability

    • Nonpharmacologic treatment:

      • Aggressive rehab after acute events
      • 80% of patients use complementary or alternative medicine
      • Yoga
      • Cannabis extracts

    • Pharmacology:

      • Symptomatic treatments
      • Disease-modifying agents
        • Have the potential to change the long-term sequelae of disease progression
        • Very expensive, long-term medications
        • Many side effects
        • Poor adherence very common
        • Interferon type medications
        • Other immune modulators### Guillain-Barré Syndrome (GBS)

    • Approximately 15% of patients experience residual weakness after 3 years.

    • The International Guillain-Barré Syndrome Outcome Study (IGOS) is an internationally collaborated prospective trial aiming to examine outcomes of GBS based on clinical and biological determinants and predictors.

    Myasthenia Gravis

    • Normally, impulses travel along the nerve to the ending, releasing acetylcholine, which binds to acetylcholine receptors, generating muscle contraction.
    • In Myasthenia Gravis (MG), a person's own antibodies block, alter, or destroy acetylcholine receptors, preventing muscle contraction.
    • MG is a disease of skeletal muscle acetylcholine receptors, where acetylcholine is unable to bind to receptors on the postsynaptic membrane to transmit nerve impulses to muscle fibers.
    • The thymus is believed to be the site of antibody production in MG.
    • 80% of MG patients have thymus hyperplasia or thymus tumor.
    • 80-90% of MG patients have auto-antibodies directed at acetylcholine receptor sites.

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    Description

    This quiz covers the guidelines for diagnosing and imaging lower back pain, including the use of red flags and plain lumbar spine x-rays.

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