Neurology [BACK PAIN]

Introduction
The spinal cord runs through the vertebrae of the spine, protected
from external injury. Muscles attach to the spine on the outside.
Any disruption to muscle, bone, or cord can produce back pain.
Since musculoskeletal pain is the most common cause of back
pain, finding reasons to look for deeper problems becomes
critical. Most patients do not require additional testing.
Diagnostic testing should be reserved for those with progressive
neurologic deficits, failure to improve after 6 weeks, and in those
who you strongly suspect an underlying diagnosis. The diagnostic
step of choice often begins with X-ray, though the MRI is
always best. A CT scan may be used in cases where the MRI is
contraindicated (Pacemaker).

1. Cord Compression
Irrespective of the underlying condition, any warning symptoms
of cord compression (see the chart to the right) warrant immediate
investigation. This is a neurologic emergency. Intervention
significantly improves morbidity (increased ambulation after
treatment) - especially when started early. If any alarm symptoms
are found the thing to give is dexamethasone (immediately).
Since symptoms have already manifested themselves look for
something big and obvious with an X-ray. If positive, it’s
positive. If negative, follow up with an MRI. Most things will
respond to radiation or surgery.

2. Musculoskeletal Warning Symptoms

This is the most common cause of back pain. It typically has an History of Cancer
inciting event (heavy lifting, straining), though none may be Urinary Symptoms (Incontinence or Retention)
found on questioning. The pain is symmetric, in a belt-like Sexual Dysfunction (ED or Priapism)
fashion, and described as an ache. In the absence of neurologic Bilateral Lower Extremity Weakness
or systemic symptoms do nothing. Just give analgesia, exercise, Sensory Deficits in a Dermatome
and stretching. If symptoms do not improve, follow up with an Fever
XR then MRI. Give the patients 4-6 weeks before returning. It
typically occurs in people > 30.

3. Herniation
In the patient where musculoskeletal pain is being considered, one
must rule out herniated disk. The age group and exacerbating
factors are the same. However, people with herniation will have
a lightning or shooting pain down the leg (“sciatica”),
exacerbated by hip flexion, movement, cough, or activity.
Assess plantar flexion (L4) and Dorsiflexion (L5), the common
nerves impinged by a bulging disk. Here’s the deal:
neurosurgery is better than conservative at 6 months, but they’re
the same at 1 year.

4. Osteophyte
If you’ve found a patient that might have a herniation (they have
that shooting lightning pain) but is an elderly male think
osteophyte, a simple bone growth into the exit of the nerve route.
Get an XR then MRI to rule out a compression fracture. Here,
neurosurgery is better than waiting.

5. Compression Fracture
In an elderly patient with back pain and a history of
osteoporosis suspect a fracture. Do an X-ray, see the fracture,
and get a neurosurgeon or orthopedist to fix it. There is usually
point tenderness or a vertebral step off and warning symptoms
may be present. These may occur with trauma, but only in the frail
old ladies who fall on their butt (coccyx).

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 Neurology [BACK PAIN]

6. Spinal Stenosis
Typically found in an elderly patient presenting with a unique
form of “sciatica.” There’s often leg and butt pain that sounds
like claudication but is positional (when upright with exercise
symptoms, when hunched over symptoms). Do an MRI to
confirm it and Surgery to fix it.

From here on we can talk about other non-traumatic causes of

neurologic symptoms or back pain. You can turn your eyes off if
you’re reading this for surgery.

7. Syringomyelia
A pocket of CSF bulges into the anterior cord that produces back
pain and loss of pain/temperature sensation, sparing
proprioception. As it expands motor and sensation will be
compromised. MRI diagnosis it, surgery corrects it.

8. Abdominal Aortic Aneurysm

If a patient has a history of HTN, CAD, and Smoking, they might
have an AAA. With AAA, the anterior spinal artery can be
affected; it produces a spastic paralysis and a loss of
proprioception. The back pain is from visceral compression (i.e.
an aneurysm that is about to pop). It can be screened via an
ultrasound. If there are neurologic symptoms it also requires an
MRI and Surgery.

9. Visceral Organs
Finally, visceral organs can refer to the back. In particular,
diarrhea/constipation and GYN issues can cause back pain. Ask
about neurologic symptoms. When negative, send them home on
NSAIDs. If in the clinic and patients explain of intermittent low
back pressure, especially relieved by flatulence or passing stool,
you’ve got your answer.

Age Risk Factors First Best Tx

Cord >50 Cancer, IVDA Steroids MRI Dx Dependent
Compression
Musculoskeletal 20-50 Heavy Lifting, None Unless no NSAIDs
Straining Improvement
Herniation 20-50 Heavy Lifting, XR MRI Bed Rest, NSAIDs
Straining
Osteophyte >50 Aging XR MRI Surgery
Compression Fx >50 Osteoporosis XR Ø Surgery
Spinal Stenosis >50 Aging XR MRI Surgery
Visceral Organs Any Age Anything XR - -
AAA >50 Smoking, HTN< - -
Atherosclerosis
Syrinx Any Age Trauma - -

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