Transcript: Diagnostic Approach To Back Pain

​Liz Rohr:
Well, hey there, it's Liz Rohr from Real World NP. You are watching NP Practice Made Simple, the weekly videos to help save you time, frustration and help you learn faster so you can take the best care of your patients.

In this week's episode, I'm going to be talking to you about back pain. So back pain as a chief complaint in primary care is so, so common. So I'm going to be talking about the approach to diagnosis and the initial management steps, and definitely covering the red flags.

So with back pain, it is one of the most common chief complaints in primary care. I really use a triage-based approach, which is basically the way that I approach everything if you've been following me for a little bit, you know it's coming. So whenever it comes to back pain, it's a triage-based approach, and I have a systematic approach to seeing that patient, any patient with any chief complaint of basically any kind, like a symptom-based visit.

So I use an OLD CART acronym, onset, location, duration characteristics, et cetera, et cetera. And then again, the hacked way to do this, if you're not super comfortable with all the differential diagnoses, is to pick that ORS system that works for that chief complaint and asking all of the questions.

One thing that is super helpful for common chief complaints like this that can be stressful to work up, especially because it's so common and patients usually want something that's not indicated for them, is having a quick text HPI that you can put in your EHR so that you can remember what questions to ask that are specific to back pain. So again, OLD CART, ORS, specific to low back pain, lower back pain in particular.

So the triage-based approach is, first questions first, is this traumatic or is it not traumatic? Did you have a fall? Did you have a car accident? What is the risk here for some sort of fracture? Because those patients get imaging, that's included if you have a trauma-related back pain, especially if it's under four weeks. Again, that's the first question, traumatic or non-traumatic?

The second question is how long ago did this start? And is this acute, subacute or chronic? And again, I always ask this in every visit, but is it better, worse, or the same? Those are just my anchoring, kind of like everyone gets that question. Tell me where we're at.

I just cut to the chase for the next part, which are the red flag questions. And so the things you're trying to elicit, number one, whenever it comes to back pain, are there any signs of a cauda equina syndrome? So do you have any numbness or tingling in your pelvic area? These can be tricky questions to elicit, but what you're trying to understand is do they have sensation of their pelvic floor area? Is it numb when the wipe, for example, when they go to the bathroom? That's one way to ask that question. Do you have any bowel or bladder disturbances? Which again, you really have to get into that question because patients don't really know what that means. It has to do with urinary retention or incontinence, either one of those. Basically with cauda equina syndrome, you lose innervation to the bladder and so it gets full and full and full until you have a sudden loss of continence because the bladder's over full.

So for example, I was a patient with not cauda equina syndrome, but something that really scared me into thinking that it was that, and they actually did a bladder scan in the ER and they were like, oh no, you're actually fine. You can wait, you probably need some imaging, but you can wait because of that phenomenon. But anyway, that's neither here nor there.

But that's what we're trying to elicit with bowel or bladder dysfunction. The other thing that is an indicator for cauda equina is loss of neurologic function of the lower extremities potentially. Or just you just want to ask that in general, it may not necessarily be related to cauda equina, but do you have any loss of sensation in your lower extremities? Do you have any weakness?

And again, objective and subjective weakness, because sometimes people have back pain and they can't lift their leg because it hurts their back versus can they try to do something and then they can't. So those are the tricky eliciting questions you have to get for that history, specific question.

A couple of other red flags that you want to think about are, that's primarily for cauda equina, saddle anesthesia, bowel or bladder incontinence, weakness, numbness, loss of function, et cetera. The other kind of general red flag you want to watch out for are, what are the other things that could potentially be felt in the back, but are not necessarily a musculoskeletal back problem.

So that's something like a pyelonephritis, do they have a high fever, nausea, vomiting, chills, et cetera, other symptoms of pyelonephritis? And do they have a sudden onset of a tearing, splitting pain like AAA? That's really uncommon in primary care. But just one thing to keep in your mind that you can definitely feel it in the back. And again, is it mid back, lower back? I'm specifically talking mostly about lower back in this situation, but you can have other visceral organ pain that transmits to the back, like you have cholecystitis, cholelithiasis, pancreatitis, things like that.

And then the only other red flag diagnosis, that you have to work backwards a little bit, it doesn't necessarily have a hallmark symptom, but you can have metastatic cancer to the spine. So any history of cancer is really important, the patient's risk factors, including their age, things like that are important to consider. So there aren't necessarily, again, hallmark symptoms in the HPI that you're getting that are related to that, but that's just something you want to keep in mind.

Again, you want to think about fractures, trauma, and then epidural abscesses can happen, especially again, what are your risk factors? Is there any IV drug use? Things like that. Osteomyelitis, those are the main red flag differentials and symptoms to watch out for.

So again, traumatic or non-traumatic? When was the onset? Is this acute, subacute or chronic? And then what are those red flags? Just asking all those red flags. Again, making a quick text so that you don't forget.

And then the next steps really depend on the history. Is it something that hurts when they move? Is it there all the time? Does it come and go? Is it helped with medications? Things like that. So when it comes to the physical exam, you're keeping all those things in mind. So what are the body systems that could be contributing to this back pain?

Most of the time in primary care, it's musculoskeletal. So it's either related to bone, related to muscle, it could be visceral organs, it could be pyelonephritis, pancreatitis, cholecystitis, et cetera, any of those things.

So you want to do your physical exam, you want to palpate the spine, you want to observe the area, you want to do an abdominal exam, you want to palpate the muscles. One of the things that I found a little bit tricky to learn when I was a newer clinician was about muscle spasm, and what feels like muscle spasm and what does not.

Is there any point tenderness on the spine itself? And then the other tests, and again, you want to look at the skin, all that other stuff. CVA testing if you're concerned about pyelonephritis if they have concordant symptoms, et cetera.

And then the other thing you want to test are specific to musculoskeletal back pain. So you want to do that straight leg test, straight leg raise test, and you're trying to see is it pain in the back, pain down the leg, numbness or tingling down the leg? And at what degree of flexion that you're bringing the leg up as they're laying down. If they're capable of doing that. If they're in too much pain, then you do your best.

The other thing to assess when they're laying flat is the FABER test, the Patrick's test, I think it's Fadir and FABER, I always say those wrong, but anyway, you're assessing for the hips. So it could be the spine or it could be referred pain from hip related etiologies. And so I can link to that down below this video. But it's F-A-B-E-R. So it's that figure four test. You probably learned about that in school. Anyway, you can look at that down below.

And then always doing strength testing. So I use the back of, again, these are little pearls, but I use the back of my hand because hand to the body is a much more intimate touch than the back of the hand to the body. And so I just prefer to do that anytime I'm assessing a patient, unless it's really important that I'm using the front of my hand and the front of my fingers. So especially if I'm assessing their leg strength, I'm putting the back of my hand onto their leg and they're lifting up, they're pushing down, they're kicking out, they're dorso flexing. Is that right? They're flexing their feet, whatever word I'm supposed to use there. They're pointing and flexing the feet, all of those things. And you're assessing that from a level of one to five.

Most of the time in primary care this is a chronic musculoskeletal chief complaint. However, you're doing your due diligence to look at all the other things. The main reasons to get imaging is if you're suspecting something like osteoarthritis, any sort of risk for cancer. We want to look if there's any lesions on the spine itself with an x-ray. Or if they've had trauma.

However, the next thing to consider is if they have any of those symptoms of cauda equina, definitely number one, get a colleague or a supervisor involved, they probably need an MRI. Or if they have neurologic deficits of any kind, plus or minus, take that with a grain of salt.

But I think this is an entry point pearl of practice is that I see a lot of new grads who follow an algorithm, and they go one, two, three, four. And that's great because algorithms are beautiful. And also just being cautious about the tests that we're ordering, when and why. So take that all with a grain of salt.

And I definitely recommend, if you're thinking, hey, I might need an MRI, pause, ask somebody, do a little bit more reading and see if it's justified. Because I think I'm just trying to give a high level here. And I don't want you to be like, oh, Liz told me to order an MRI. Let's leave it at that.

But anyway, the most important thing to remember about x-rays is that you need to have a clinical suspicion, trauma, osteoarthritis, worried about a lesion of some kind. Because most people, we did a research thing about this in grad school, I imagine you've done something similar, but those are very low yield tests for patients who have musculoskeletal muscle spasms for example. But most patients who come in want an x-ray, but that is very low yield.

For patients that you are suspecting is a musculoskeletal etiology based on your exam and your history, those can take between four to six weeks to get better. I always recommend patients seek physical therapy pending there are no red flags or other differential etiology potentials in an outside category from musculoskeletal. Because they can do their assessment a lot more sophisticated than I can, as well as give treatment recommendations for that patient to either do with them in physical therapy or at home.

And the main thing, definitely, definitely, definitely watch the interview I did with a physical therapist, if you have not already. It gives just so much wisdom about physical therapy itself. But one of the main pearls of that interview is that it is our job to set the patients up for success with their expectations of seeing physical therapy and their recovery time.

Personally, when I had that back injury that brought me into the ER, it took at least nine weeks, nine to 12 weeks, to feel the acute phase getting better despite all the medications, despite the physical therapy. It took a long time. And the prolonged recovery has taken a lot longer.

So one little pearl to take away for those musculoskeletal back pain people is setting of expectations. And also advising them of the red flags that you've already asked about because if it gets worse, they know to come back. But that's the moral of the story with low back pain approach to assessment, diagnosis, and first steps.

So that's our episode for today. If you haven't grabbed the Ultimate Resource Guide for the new NP, head over to realworldnp.com/guide. You'll get these episodes sent straight to your inbox every week with notes from me, patient stories and bonuses I really just don't share anywhere else.

Thank you so very much for watching. Hang in there and I'll see you soon.