366.1 🎓 醫孞生版

366.1.0.1 📌 䞀頁重點

366.1.0.1.1 Classification

366.1.1 By Duration

  • Acute < 6 weeks
  • Subacute 6-12 weeks
  • Chronic > 12 weeks

366.1.2 By Etiology

  • Non-specific (mechanical) ~ 85%
  • Radicular (compression of nerve root)
  • Neurogenic claudication (spinal stenosis)
  • Spondyloarthritis (inflammatory)
  • Spinal cord compression (myelopathy)
  • Serious specific (fracture, malignancy, infection, cauda equina)
366.1.2.0.1 Red Flags (Get Imaging + Workup)

Cancer: - Age > 50 - History of cancer - Unexplained weight loss - Pain at night / rest - Refractory > 4-6 weeks

Infection: - Fever - IV drug use - Immunosuppression - Recent procedure - Bacteremia

Fracture: - Trauma (any age) - Older + minor trauma - Osteoporosis history - Chronic steroid use

Cauda Equina (EMERGENCY): - Saddle anesthesia - Urinary retention/incontinence - Bowel dysfunction - Bilateral leg weakness - Bilateral leg numbness

Spinal Cord Compression: - UMN signs (hyperreflexia, Babinski, clonus) - Bilateral signs - Bowel/bladder - Sensory level

366.1.2.0.2 Common Specific Causes

366.1.3 Lumbar Disc Herniation (Radiculopathy)

  • Most common L4-L5, L5-S1
  • Acute or recurrent
  • Sciatica (radiating down leg)
  • Specific dermatomal pattern
  • Positive straight leg raise (SLR)

Patterns: - L4 root: anterior thigh, medial leg; knee jerk ↓; foot inversion weakness - L5 root: lateral leg, dorsum foot, great toe; foot drop (tibialis ant), great toe extension; SLR - S1 root: posterior leg, lateral foot; plantarflexion weakness; ankle jerk ↓

366.1.4 Cervical Disc Herniation / Radiculopathy

  • C5-C6, C6-C7 most common
  • Neck + arm pain

Patterns: - C5: lateral arm; deltoid; biceps reflex ↓ - C6: lateral forearm, thumb; biceps; brachioradialis reflex ↓ - C7: middle finger; triceps reflex ↓ - C8: little finger; intrinsic hand - T1: medial arm; hand

366.1.5 Spinal Stenosis (Neurogenic Claudication)

  • Older
  • Pain/numbness/weakness with walking/standing, relieved by sitting/flexion
  • “Shopping cart sign”
  • Bilateral
  • Distinguished from vascular claudication:
    • Pulses normal
    • Walking distance variable
    • Relief by flexion (not just rest)

366.1.6 Cauda Equina Syndrome

  • EMERGENCY
  • Causes: massive central disc, tumor, hematoma, abscess
  • Symptoms:
    • Saddle anesthesia
    • Bilateral leg weakness/numbness
    • Urinary retention (overflow incontinence)
    • Bowel dysfunction
    • Decreased rectal tone
  • Urgent MRI + surgical decompression within 48 hr

366.1.7 Vertebral Compression Fracture

  • Osteoporosis (postmenopausal women, elderly)
  • Chronic steroids
  • Minor trauma or spontaneous
  • Acute pain
  • Imaging
  • Treatment: pain control, bracing, kyphoplasty for select

366.1.8 Spinal Epidural Abscess

  • Triad: back pain + fever + neuro deficit (only 13% have all)
  • IV drug use, immunosuppression, bacteremia, recent procedure
  • ↑ ESR, CRP, WBC
  • MRI with gadolinium
  • Treatment: surgical drainage + antibiotics

366.1.9 Metastatic Disease

  • Common primaries: breast, lung, prostate, kidney, thyroid, multiple myeloma
  • Bone scan, MRI
  • Symptoms: pain at rest, night, progressive
  • Risk of cord compression → emergency

366.1.10 Ankylosing Spondylitis / Axial SpA

  • Young (< 45 at onset)
  • Inflammatory back pain (morning stiffness > 30 min, improved with exercise)
  • Bilateral sacroiliitis
  • HLA-B27
  • Treatment: NSAIDs, TNF inhibitors, IL-17 inhibitors, JAK inhibitors
366.1.10.0.1 Workup

366.1.11 History

  • Onset (sudden, gradual)
  • Quality, location, radiation
  • Aggravating/relieving factors
  • Red flags
  • Function impact
  • Medications, comorbidities

366.1.12 Physical Exam

  • Inspection (alignment, deformity)
  • Palpation (vertebrae, paraspinal, sacroiliac)
  • Range of motion
  • Neurological (motor, sensory, reflexes)
  • Special tests (SLR, FABER, Spurling, Hoffmann)

366.1.13 Imaging

No imaging if: - Acute non-specific LBP < 6 weeks - No red flags

Imaging if: - Red flags present - Failure to improve > 6 weeks - Severe/progressive neuro deficit (urgent MRI)

Modality choice: - X-ray: alignment, fracture, spondylolisthesis (limited soft tissue) - MRI: best for soft tissue (disc, cord, nerve roots, abscess, tumor) - CT: bone, fracture detail - Bone scan: metastases - DEXA: osteoporosis

366.1.14 Labs (if Red Flags)

  • CBC (infection)
  • ESR, CRP (infection, inflammation)
  • CMP
  • Calcium, alkaline phosphatase, PSA (malignancy)
  • SPEP (myeloma)
  • HLA-B27 (axial SpA)
366.1.14.0.1 Treatment

366.1.15 Non-Pharmacologic (First-Line)

  • Stay active (bed rest worse)
  • Physical therapy
  • Cognitive behavioral therapy
  • Heat/cold
  • Massage
  • Acupuncture
  • Yoga
  • Spinal manipulation (limited evidence)

366.1.16 Pharmacologic

  • NSAIDs first-line (oral, topical diclofenac)
  • Muscle relaxants (cyclobenzaprine, baclofen, tizanidine) short-term
  • Acetaminophen (limited evidence in LBP)
  • Topical lidocaine, capsaicin
  • Duloxetine (chronic LBP)
  • Gabapentinoids (for radicular pain)
  • TCAs (chronic)
  • Opioids — avoid chronic; short-term only if other failed

366.1.17 Interventional

  • Epidural steroid injection (radicular pain)
  • Facet joint injection
  • Radiofrequency ablation (facet-mediated pain)
  • Intradiscal procedures
  • Spinal cord stimulator (refractory)

366.1.18 Surgical

Indications: - Cauda equina (EMERGENCY) - Progressive neuro deficit - Refractory radiculopathy > 6 weeks - Spinal stenosis with disability - Spondylolisthesis with deficit - Tumor, infection, instability

Procedures: - Microdiscectomy - Laminectomy - Fusion (when instability) - Kyphoplasty (compression fracture, select)

366.1.18.1 🩺 床邊速查

  • 85% non-specific — stay active + NSAIDs + PT
  • Red flags (cancer, infection, fracture, cauda equina EMERGENCY)
  • Imaging only if red flags or > 6 weeks no improvement
  • Cauda equina = saddle anesthesia + urinary retention + bilateral leg weakness → urgent MRI + decompression within 48 hr
  • Spinal epidural abscess: back pain + fever + neuro deficit (only 13% all 3)
  • Spinal stenosis = walking pain relieved by flexion (“shopping cart”)
  • Disc herniation = radicular dermatomal + SLR positive