New Treatment of Lower Back Pain
A 70-year-old white male presents to the emergency department with sudden onset of severe back pain. The pain is described as severe and constant without alleviating or aggravating symptoms. He has never had pain like this before. He denies chest pain, shortness of breath, or loss of consciousness. He denies any history of an abdominal aortic aneurysm. His past medical history is significant for hypertension, and chronic obstructive pulmonary disease that requires home oxygen therapy. He had bilateral inguinal herniorrhaphy some years ago, but has never had a laparotomy.
D.C., 1972), a laminectomy (surgical removal of the posterior arch of a vertebra) was performed for severe back pain. On the following day, the patient fell out of bed causing major paralysis. The patient had not been warned that a laminectomy might increase the danger of paralysis as a result of such eventualities as falling out of bed. A second operation failed to relieve the paralysis, and though the patient did improve, he never returned to normal. The court ruled that information material to the decision must be disclosed. It said that a risk was material when a reasonable person, in what the physician knows or should know to be the patient's position, would be likely to attach significance to the risk or cluster of risks in deciding whether or not to forego the proposed therapy. The court went on to say the patient's right of self-decision can be exercised only if the patient possesses enough information to enable an intelligent choice.
Rhythmic, involuntary contractions of the uterus accomplish the process of birth which is called parturition. These involuntary contractions (also called labor pains) become more intense, last longer, and occur closer together in time until they finally cause the cervix to dilate (to open) to a diameter of 10 cm (4 inches). As the uterine contractions become stronger, longer, and closer together, abdominal muscles contract, causing the woman to feel like bearing down or pushing. Contractions of two sets of muscles (uterine and abdominal) expel the fetus and the placenta. The woman often feels uterine contractions as high or low back pain.
A 74-year-old male was admitted to the hospital having sustained a crush fracture of the third lumbar vertebra while lifting a heavy box. He required opiate analgesics for the pain, which radiated to his right leg, and his mobility was severely limited. He made little progress in spite of analgesia and physiotherapy hence, he was transferred to a geriatric rehabilitation unit, where he subsequently developed ulceration of his left heel. The ulcer was found to be suitable for community care, and as his back pain improved he was discharged home.
Indirect costs include the impact on productivity, days lost from work, forgone leisure time, and increased mortality. Compared with other chronic conditions, the costs associated with depression are more likely to be productivity losses caused by absenteeism and suboptimal performance in the workplace 3, 30, 37, 42 . Depressed workers can experience short- and long-term absences from work leading to reduced earnings capacity over time 43 . One study has found that the magnitude of short-term disability appears to be greater than other chronic conditions such as diabetes, back pain, and high blood pressure 44 . The costs of depression are therefore more hidden and insidious than those associated with other chronic illnesses.
Ly - can be used, but this diagnostic procedure is somewhat invasive and may cause discomfort 5 . Moreover, microneurography has the greatest utility for the long nerves of the legs and arms, and thus those chronic pain syndromes with primary presentations in the trunk or face (e.g. lower-back pain or post-herpetic neuralgia) are difficult to analyze. Consequently, there are very few published studies that have correlated successfully nociceptive nerve fiber hyperactivity with patient reports of chronic pain, and they all involve neuropathic pain of the extremities. For instance, a systematic study of hyperactive nociceptors in patients with erythromelalgia (burning pain of the feet) showed altered conduction velocities and spontaneous activity or sensitization in some mechano-insensitive C-fibers 6 .
The answer is b. (Cunningham, 20 e, pp 746-751, 755-757, 765-767.) Placenta previa and abruptio placenta are the two most common causes of third-trimester bleeding. Placenta previa is abnormal implantation of placenta near or at the cervical os, and may be total, partial, marginal, or low-lying. Risk factors for placenta previa include advanced maternal age, multiparity, smoking history, and prior cesarean section. Patients present at 30 wk gestation with painless vaginal bleeding. There is no fetal distress. Vaginal examination is contraindicated and sonogram is required to make the diagnosis. Abruptio placentae is premature separation of a normally implanted placenta. Patients present with painful (unremitting abdominal and back pain) vaginal bleeding and there is fetal distress. Risk factors for abruptio placentae include advanced maternal age, multiparity, diabetes, hypertension, tobacco use, alcohol use, and cocaine use. Placenta accreta is a placenta that adheres to the...
A 35-year-old man presents to the emergency department with intense back pain. He is hydrated and given pain medication. After several hours he passes a kidney stone. Laboratory analysis of the stone reveals that it is composed of struvite (magnesium ammonium phosphate). Infection with which of the following organisms promotes the production of such stones
A 52-year-old white woman with breast cancer receiving adjuvant therapy presents with back pain that intensifies on movement and pain over the L1 vertebral body when she coughs and that radiates down her left lower extremity to her leg and foot. The most likely etiology of this disorder is
The patient had been complaining of fever, malaise, headache, myalgias, back pain, abdominal pain, nausea, and vomiting for the past week he also complained of extremely reduced urine output. Careful history revealed that before he fell ill, he and his friend were cutting wood in the forest when they accidentally disturbed a rodent-infested area.
If the baby is facing forward rather than backward, you may feel the lumpy arms and legs rather than the rounded back. This is usually no big problem, but labor may be longer and cause the woman more back pain. She should change positions often, as this may help turn the baby. Have her try on her hands and knees.
In the newborn period there are no clinical features as there is still Hb F and not much Hb S. During the first 2-4 months, hemolytic anemia develops, and by 5-6 months patients develop the hand-foot syndrome, i.e., dactylitis. Dactylitis is usually the first manifestation of sickle cell disease, and infants present with painful symmetric swelling of the hands and feet secondary to poor blood flow to the expanding marrow spaces. From 6 months to 5 years the spleen auto infarcts, predisposing the patient to encapsulated organisms such as Streptococcus pneumoniae and H. influenzae. Splenic sequestration, i.e., acute splenic engorgement, can lead to shock and death. From 6 months to a lifetime vasoocclusive episodes precipitated by intercurrent illness is the most frequent manifestation. Young children may complain of painful extremities. Older children may present with chest pain, back pain, and abdominal pain that mimics a surgical abdomen.
A 59-year-old man presented with an abdominal aortic aneurysm (AAA) discovered on duplex scan examination of the abdomen. The AAA was 60-mm large and extended to the left common iliac artery. The patient was otherwise asymptomatic, with no abdominal or back pain. His medical history was significant for hypertension controlled by bitherapy, non-insulin-dependent diabetes diagnosed 5 years previously, claudication with a walking distance of 400 metres, and a smoking history of 40 packs year. He had no history of myocardial infarction (MI) or angina pectoris.
A high index of suspicion is paramount in clinching the diagnosis. Any patient with a known AAA who presents with sudden severe abdominal or back pain has a ruptured aneurysm until proven otherwise. The difficulty arises in atypical presentations of patients with unknown aneurysmal disease leading to detrimental delays in surgical management. Ruptured AAA should feature in the differential diagnosis of any patient who presents with unexplained hypertension, severe abdominal pain, or cardiac arrest with no prior history of myocardial disease or trauma.
BoNT A use has now been reported to be effective in well over 100 different clinical conditions (see reviews in References 55 through 58). In addition to effects on muscle contraction and autonomic conditions, recent therapeutic benefits reported for botulinum neurotoxin preparations, particularly BoNT A, have included relief of a range of pain conditions, for example, myofascial pain syndromes, lower back pain, and various chronic headache syndromes including migraine.59,60
(1) Hemolysis of transfused RBCs occurs infrequently, but may cause a severe reaction accompanied by hemoglobinemia, hemoglobinuria, hypotension, disseminated intravascular coagulation, acute renal failure, and death. Initial recipient symptoms are not diagnostic of hemolysis and often consist of flushing, a feeling of apprehension, chest or back pain, chills, fever, and nausea or vomiting. During anesthesia, the development of diffuse bleeding may be the only evidence of a hemolytic reaction. Red blood cell destruction may be primarily intravascular, as seen with ABO-incompatible RBC infusion or predominantly extravascular as in Rh incompatibility. Intravascular hemolysis usually occurs much more rapidly, and is more likely to result in recipient harm than the relatively slow extravascular removal of RBCs by the reticuloendothelial system.
The health insurance claims of over 400,000 employees and dependents of several large American corporations were analyzed for frequency of diagnostic imaging. The frequency of imaging and Imaging charges were compared for two groups of physicians (1) primary physicians with their own diagnostic imaging equipment (self-referring physicians) and (2) primary physicians who referred patients to radiologists (radiologist-referring physicians). Four clinical presentations were selected for their variety and volume of associated imaging procedures 1) acute upper respiratory symptoms (how many chest radiographs were performed ) 2) pregnancy (how many ultrasounds were performed ) 3) low back pain (how many radiographs of the lumbar spine were performed ) and 4) difficulty urinating in men (how many excretory urograms, cystograms, or ultrasounds were performed ). The study revealed that for the clinical presentations considered in this study, patients were four times as likely to have...
In addition to its diagnostic value, ultrasound technology can also function as a treatment modality. At a frequency higher than that required for diagnostic purposes, ultrasound is used to produce heat in body tissues that treat or relieve back pain. Ultrasound is also used to produce sound waves that are able to pulverize kidney and gallstones in a procedure called percutaneous ultrasonic lithotripsy (PUL).
A 54-ycar-old nurse complains of a heavy sensation in her lower abdomen that worsens when she lifts heavy objects, together with back pain and increased frequency of urination with a burning sensation (due to altered location of bladder, subsequent stagnation of urine, and thus bacterial proliferation).
A 76-year-old woman is admitted to the hospital for weight loss and back pain. She is found to have metastatic breast cancer. The family is waiting outside the room when you are on your way to inform the woman of the diagnosis. The family asks you not to tell the patient. It would devastate Iter, the patient's daughter lei Is you. Vou tell the family thaL you feel it is your obligation to inform the patient of the diagnosis, and they get upset because they know the patient much better than you do and know what is best for her. What should you do
The onset was gradual, with prodromal symptoms of headache, malaise, backache, and chills. These symptoms were followed by shaking chills, fever, and a more severe headache accompanied by nausea and vomiting. A remittent pattern of fever accompanied by tachycardia continued for 10-12 days, with the rash appearing around the fifth day of fever. The patient worked at a rat-infested food-storage depot this summer.
A 62-year-old African American man presents with fatigue, decreased urine stream, and low back pain. The physical examination shows a hard, nodular left prostatic lobe and percussion tenderness in the lumbar vertebral bodies and left seventh rib. The next step in evaluation is
Recent studies suggest that a minority of patients presenting with lumbar disc protrusion will have voiding dysfunction. Bartolin et al. (1) prospectively studied 114 patients (37 women, 77 men) who complained of low back pain and were found to have lumbar disc protrusion requiring surgical treatment. Of this group, 31 (27.2 ) were found to have detrusor areflexia, whereas detrusor activity was normal in the remaining 83. Specifically, 3 of 8 with L3, 10 of 54 with L4, and 18 of 52 with L5 disc protrusion had detrusor areflexia. All of these 31 patients reported difficulty voiding requiring straining. Clearly, this is a select group as many patients do not require surgery and likely have less severe disc prolapse. Those with less severe prolapse probably have a lower rate of voiding dysfunction as well. In contrast to this report, Rosomoff et al. (2) reported rates of voiding dysfunction as high as 92 however, his study had far less stringent diagnostic criteria for areflexia than...
Deficiency, or infectious neuropathies such as herpes simplex should be noted. Careful questioning concerning lower back pain, gait disturbances, or any other symptoms that were present when the voiding dysfunction began can be helpful. For example, the presence of flu symptoms and gait disturbance in the past may be related to an infectious neuropathy. Sensory examination of the perineal area and lateral foot (both associated with sacral segments) may give clues to a neurologic origin. The BCR and anal sphincter tone as well can suggest a lesion involving sacral segments or nerve roots. Assessment of the patients postvoid residual using either a straight catheter or an ultrasound bladder-scan device can also give information on the efficiency of bladder emptying.
A 49-year-old woman comes to the emergency department because of severe abdominal pain for the past few bours. She says that it feels as if someone were stabbing her in the stomach and it is worse after she eats. She also complains of back pain. Physical examination shows epigastric tenderness. Laboratory studies show
A 62-year-old woman comes to the gynecologist's office complaining of low back pain and pressure sensation in the perineal area. The patient states that this has been occurring for a year and a half and she has been recommended by another physician to wear a pessary. At the present time she is reluctant to wear a pessary. On pelvic examination a second-degree uterine prolapse with a cystocele and a rectocele is observed.
Multiparous women (those who have had two or more pregnancies resulting in viable fetuses, whether or not the offspring were alive at birth) or patients who receive multiple transfusions may develop antibodies to leukocytes and platelets. When patients with leukocyte antibodies receive blood containing incompatible leukocytes, febrile transfusion reactions may occur. These leukocyte reactions do not cause red blood hemolysis, but can be extremely uncomfortable for the patient and are potentially fatal. Symptoms such as chills, fever, headache, malaise, nausea, vomiting, and chest or back pain may persist for up to 8 hours and seem to be caused by immune damage to donor leukocytes. The frequency and severity of leukocyte transfusion reaction is directly related to the number of incompatible leukocytes transfused. Therefore, leukocyte-poor blood (LP-RBCs) is indicated for patients who have repeated febrile transfusion reactions. Because febrile...
The workplace is slowly awakening to the impact that mental health, and particularly depression, has on its bottom line. The few employers who track disability are discovering the impact that depression has in terms of duration and chronicity. In a study of our corporation's experience that extended the observational period of our 1994 paper 1 , depressive disorders maintained their primacy over common chronic medical-surgical disorders such as heart disease, low back pain, and diabetes in terms of the average length of disability duration 2 . The likelihood of a return to disability status within 12 months of an initial disability period also remained high relative to the other disorders.
While you are on call at the hospital covering labor and delivery, a 32-year-old G3P2002 who is 35 weeks calls you complaining of lower back pain. The patient informs you that she had been lifting some heavy boxes while fixing up the baby's nursery The patient's pregnancy has been complicated by diet-controlled gestational diabetes. The patient denies any regular uterine contractions, rupture of membranes, vaginal bleeding, or dysuria. She denies any fever, chills, nausea, or emesis. She reports that the baby has been moving normally On physical exam, you note that the patient is obese her cervix is long and closed. Her abdomen is soft and nontender with no palpable uterine contractions. No flank pain can be elicited. She is afebrile. The external monitor indicates a reactive fetal heart rate strip there are rare irregular uterine contractions demonstrated on toco. The patient's urinalysis comes back with trace glucose and protein, and is otherwise negative. The patient's most...
A 53-year-old woman presents with complaints of weakness, anorexia, malaise, constipation, and back pain. While being evaluated, she becomes somewhat lethargic. Laboratory studies include a normal chest x-ray serum albumin, 3.2 mg dL serum calcium, 14 mg dL serum phosphorus, 2.6 mg dL serum chloride, 108 mg dL BUN of 32 mg dL creatinine of 2.0 mg dL.
ID CC A 54-year-old nurse complains of a heavy sensation in her lower abdomen that worsens when she lifts heavy objects, together with back pain and increased frequency of urination with a burning sensation (due to altered location of bladder, subsequent stagnation of urine, and thus bacterial proliferation).
After a thorough assessment of a patient's presenting symptoms, the history should then focus on related areas. There are several aspects of a patient's history that may be intimately related to voiding function. Sexual and bowel dysfunction are often associated with voiding dysfunction. Therefore the review of symptoms should focus on these areas including defecation (constipation, diarrhea, fecal incontinence, changes in bowel movements), sexual function, dysparunia, and pelvic pain. As neurological problems are frequently associated with voiding dysfunction, a thorough neurological history is critical, including known neurologic disease as well as symptoms that could be related to occult neurological disease (back pain, radiculopathy, extremity numbness, tingling, or weakness, headaches, changes in eyesight, and so on). In addition to a focused history regarding LUTS and voiding dysfunction, a thorough urological history is important. This includes a history of hematuria, urinary...
The patient's history includes one episode of acute urinary retention one month ago that was relieved with catheterization. He denies any history of hematuria (vs. carcinoma of the bladder) or back pain (vs. metastasized prostatic carcinoma). He also admits to having a reduced caliber of urine stream and terminal dribbling as well as urinary hesitancy.
A 17-year-old male presents with 10 days of progressive tingling paresthesias of the hands and feet followed by evolution of weakness of the legs two evenings before admission. He complains of back pain. He has a history of a diarrheal illness 2 weeks prior. On examination, he has moderate leg and mild arm weakness, but respiratory function is normal. There is mild sensory loss in the feet. He is areflexic. Mental status is normal.
Whether the aneurysm affects the thoracic or abdominal aorta, there are usually very few symptoms. Chronic symptoms that do occur are usually due to pressure effects on the surrounding structures. Even in quite small abdominal aneurysms, erosion of adjacent vertebral bodies can occur, leading to back pain. One of the commonest symptoms of large thoracic aneurysms is dysphagia from direct pressure on the esophagus. Patients who notice abnormal abdominal pulsation (frequently while bathing, or in bed) often present with amusing self-diagnoses that belie the serious nature of the condition. This has been called slipped-heart syndrome. unknown, are principally severe abdominal and back pain of sudden onset. The pain may radiate into the groin, flanks, or genitalia and can closely mimic renal colic. When the aneurysm is ruptured, there is also collapse and hypov-olemia. The distinction between acutely symptomatic intact aneurysms and ruptured aneurysms is impossible to make on history...
The history and physical examination are important in screening for secondary forms of osteoporosis and directing the evaluation, although they are neither sensitive enough nor sufficient for diagnosing primary osteoporosis. A medical history provides valuable clues to the presence of chronic conditions, behaviors, physical fitness, and or the use of long-term medications that could influence bone density. Patients already affected by complications of osteoporosis may complain of upper or mid-thoracic back pain associated with activity, aggravated by long periods of sitting or standing, and easily relieved by rest in the recumbent position. Low bone density, a propensity to fall, greater height, and presence of previous fractures confer increased fracture risk.
Spinal radiography is an examination of the entire spine or any section of the spine. The x-rays are used to identify a variety of spinal abnormalities as well as to assess back pain. Several views, such as anteroposterior, lateral, and oblique, are often taken and the patient must be able to cooperate in the positioning aspects of this examination. Pregnancy is a contraindication for this test.
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How To Win Your War Against Back Pain
Knowing the causes of back pain is winning half the battle against it. The 127-page eBook, How To Win Your War Against Back Pain, explains the various causes of back pain in a simple manner and teaches you the various treatment options available. The book is a great pain reliever in itself. The sensible, practical tips that it presents will surely help you bid good-bye to back pain forever.