Morning Report

7/7/1999

Victor Ghobrial, MD

William Fink, MD

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.

PMH

• HTN

• DJD

• No DM, CAD or cancer

H&P

• NKDA

• Tylenol daily

• SH: No smoking or alcohol abuse

• Family Hx: non- contributory

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

H&P

• 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

Labs

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

• Glucose 120

• CXR

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

• 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

• Trauma : bone, joints or ligaments

• Mechanical : pregnancy, obesity or scoliosis

• Degenerative : osteoarthritis

• Infections : osteomyelitis, TB, meningitis

• Metabolic : osteoporosis, osteomalicia

• Neoplastic : myeloma, Hodgkin’s, pancreatic Ca, breast mets, prostate, lung

• GI : ulcers, pancreatitis, cholelithiasis, IBD

• Renal : hydronephrosis, calculus, neoplasm, renal infarcts, pyelo-nephritis

• Hematological : sickle cell crisis, hemolysis

• Vascular : leaking aortic anurysm, subarachnoid or spinal he

• Gynecologic : tumors of uterus, ovary, dysmenorrhea, uterine prolapse

• Inflammatory : ankylosing spondylitis, arthritis, Reiter’s syndrome, strain

• Psycogenic : malinger, anxiety, hysteria

• 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

• Standing Position• 1- Kyphosis, lordosis

and scoliosis• 2- Localize tenderness • 3- Schober test: 10cm

line at LSJ & above should extend > 15cm

• Sitting & Supine• 1- Reflexes:

Knee(L4) Ankle(S1)• 2- SLR: + if elevated

60*or less, spes 40%, sens 95%.

• 3- Crossed Straight Leg 90&25%

• CBC & ESR :Inflammatory&Neoplastic

• Ca & Alka phos : Diffuse bone disease

• Serum & Urine Electrophoresis : MM

• Acid phos & PSA : Prostate Ca

• UA : Renal disease

• Occult Stool : GI diseases

• 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

• 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

• 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)

• 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

• 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

• Needed urgently if evidence of evolving neurologic deficits, consistent pain syndrome that failed conservative Rx for 4:6 weeks

• Percutaneous lumbar discectomy is safe and effective (75%) alternative to laminectomy