45 y.o. M, acute LBP after heay lifting

45 y.o. M, acute LBP after heay lifting

1. pt cannot straighten up

   • point tenderness over his lumber spine
     • Numbness
       • over left anterior thigh & leg
         • extends to the medial aspect of left foot & great toe
       • motor testing finds weakness in knee extension
         • diminished patellar reflex
           • positive straight leg raise on the left

2. acute pain is a protective measure of the body

   • sudden and typically goes away after the pain stimulus is removed & tissue heals. Chronic pain is long term
     • Symptoms: anxiety, tachycardia, hypertension, fever, diaphoresis, dilated pupils, moaning, touching, rocking, elevated blood sugar, decrease in gastric acid secretion & intestinal motility, decrease in blood flow to the viscera and skin, and nausea (occasionally)
       • Treatment: rest for at least a week, hot and/or cold packs, calcium with vitamin D to strengthen, physical therapy, massage, aquatics, weight bearing activities eventually, steroids to decrease inflammation, an NSAID like ibuprofen (careful consideration is necessary for cardiac patients) and opioids like oxycodone or codeine (unless the patient has a history of opioid abuse); PCP and pain management work together. Follow up is necessary to determine what works. Surgery is a last resort
         • H &H to determine hemodynamic instability, amylase & lipase levels to r/o pancreatic injury or disease, urinalysis to r/o kidney injury or disease (UTI) serum calcium level to r/o hypercalcemia, SMA if cancer considered
   • acute pain comes from cutaneous and deep somatic tissue or visceral organs; classified as acute somatic, acute visceral , or referred
     • red flags: age, how long the patient has had the symptoms, atypical pain complaints, injury or illness, medications used, frequency and duration of pain, whether or not incontinence of bowel or bladder is present, genetic conditions, herniation, fractures, tumors,and infection
     • acute pain lasts less than 6 weeks, subacute pain persists 6 to 12 weeks, chronic pain persists for more than 12 weeks
     • Pain is transmitted as an impulse from the site of injury to the brain. The peripheral nerve fibers tell the spinal cord there in pain. Next, the dorsal horn processes the transmission. Finally, the pain signal reaches the thalamus and cerebral cortex. Unrelieved pain can cause physical and/or psychologic problems

3. symptoms at presentation of patient:

   • most likely a cervical fracture: cannot straighten up, tenderness over lumbar spine, diminished patellar reflex
     • monitor for spinal shock
   • possible cauda equina: tenderness over lumbar spine, weakness in knee extension, positive straight leg raise

4. diagnosis: acute injury requires X-ray (centeroposterior& lateral films of lumbar spine. MRI to r/o lesions, CT to r/o bony spurs