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FM38 Family Medicine
Common Presenting Problems
Toronto Notes 2019
Indications for Lumbar Spine X-Ray
• No improvement after 6 wk
• Fever >38oC
• Unexplained weight loss
• Prolonged corticosteroid use
• Significant trauma
• Progressive neurological deficit
• Suspicion of ankylosing spondylitis
• History of cancer (rule out metastases)
• Alcohol/drug abuse (increased risk of
osteomyelitis, trauma, fracture)
Etiology
• sourceofpaincanbelocal,radicular,referred,orrelatedtoapsychiatricillness • 98%aremechanicalcauses(worsewithmovement,betterwithrest)
■ soft tissue: sprain (ligament), strain (muscle)
■ spine: facet joint/disc degeneration, disc herniation, spinal stenosis (e.g. spondylosis),
spondylolisthesis, compression fracture ■ other: pregnancy
• 2% are non-mechanical causes ■ surgical emergencies
◆ cauda equina syndrome (areflexia, lower extremity weakness, saddle anesthesia, fecal incontinence, urinary retention)
◆ AAA (pulsatile abdominal mass) ■ medical conditions
◆ neoplastic: primary, metastatic, multiple myeloma
◆ infectious: osteomyelitis, TB
◆ metabolic: osteoporosis, osteomalacia, Paget’s disease
◆ rheumatologic: ankylosing spondylitis, polymyalgia rheumatica
◆ referred pain: perforated ulcer, pancreatitis, pyelonephritis, ectopic pregnancy, herpes zoster
Physical Exam
• inspection: curvature, posture, gait
• palpation:bonydeformities/tenderness,paraspinalmusclebulk/tenderness,triggerpoints
■ percussion of spine to elicit pain due to fracture or infection
• ROMandperipheralpulses
• neurologicexamforL4/L5/S1helpsdeterminelevelofspinalinvolvement(power,reflexes,sensation) • specialtests
■ straight leg raise (positive if pain at <70 degrees and aggravated by ankle dorsiflexion), positive test is indicative of sciatica
■ crossed straight leg raise (raising of uninvolved leg elicits pain in leg with sciatica), more specific than straight leg raise
■ femoral stretch test (patient prone, knee flexed, examiner extends hip) to diagnose L4 radiculopathy
Investigations
• plainfilmsnotrecommendedininitialevaluation
• ifinfection/cancersuspected:CBC,ESR
• ifneurologicdeficitsworseningorinfection/cancersuspected:considerCTorMRI