問診と身体診察を極めよう、OSCEにむけて：腰痛 / Unleash your Mastery - The art of history taking and physical examination: lower back pain

Hey there,

Today, I've put together a summary on lower back pain, which is just as common as the joint pain we discussed last time.

I thought I'd share it with you all.

こんにちは～、

今日は前回まとめた関節痛と同じくらい出会うであろう

腰痛についてまとめてきたので、皆さんに共有しますね

Whether you’re in the countryside or the city, men and women alike suffer from back pain. But don’t be fooled

—it’s not always something to take lightly.

There are some types of back pain you definitely don’t want to ignore,

so let’s take a good look and review!

田舎でも都会でも、男女問わず腰痛に悩んでいる人は多いと思います

しかしながら一口に腰痛と言っても、なかなか侮れませんでした

見逃してはいけない腰痛も存在するので、ここで一度しっかりと復習していきましょう

今回も英語のボリュームがかなり多くなったので、

日本語はつけていません、、、

ご了承ください

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Lower back pain is something most of us will experience at some point in our lives.

It's one of those pesky issues that can range from a mild annoyance to a major disruption in your daily routine.

Let's dive into the different causes of lower back pain, what symptoms to look out for, and some red flags that might indicate a more serious problem.

What Causes Lower Back Pain?

Lower back pain can stem from various sources.

Here’s a breakdown:

Primary Back Pathology:

1. Musculoligamentous Injury (Lumbosacral Strain): This is often due to overexertion or physical activity.
2. Spondylosis: Degenerative arthritis of the spine.
3. Intervertebral Disc Herniation: When a disc in your spine slips out of place.
4. Anatomic Abnormalities: Such as scoliosis or spondylolisthesis.
5. Compression Fracture: Can be traumatic, spontaneous (due to osteoporosis), or pathologic (from metastatic disease).

Systemic Diseases with Back Manifestations:

• Infection: Like epidural abscess or vertebral osteomyelitis/discitis.
• Metastases: 
        Vertebrae: From lung, breast, prostate, renal, thyroid, myeloma
        Leptomeningeal Carcinomatosis: From lung, breast, melanoma, lymphoma,                                                                     leukemia
• Inflammatory Back Pain: Conditions like ankylosing spondylitis or psoriatic arthritis.

Referred Pain:

1. Aorta: Dissection or aneurysm.
2. Pancreas: Pancreatitis or pancreatic pseudocyst.
3. Kidney: Pyelonephritis, perinephric abscess, or nephrolithiasis.
4. Retroperitoneal Hemorrhage: Bleeding behind the abdominal cavity.

The Big Five: Major Types of Back Pain

Understanding the specifics can help you pinpoint what's going on. Here are the five major types of back pain:

1. Lumbosacral Strain:

• Risk Factors:
  Physical activity leading to muscle or ligament injury.
• Pain Description:
  Worsens with movement, improves with rest.
• Age of Onset:
  Any
• Exam Findings:
  Diffuse tenderness, usually not over the vertebral bodies.
• Imaging:
  Typically none needed.

2. Lumbar Disc Herniation:

• Risk Factors:
  Male sex, smoking, obesity, certain occupations.
• Pain Description:
  Acute onset, pain usually radiates to one leg (sciatica),
  worsens with sitting, improves with back extension.
• Age of Onset:
  Typically 35-50
• Exam Findings:
  Decreased sensation in a specific dermatome,
  decreased patellar or ankle reflex,
  positive straight leg raising (SLR) test.
• Imaging:
  MRI confirms the diagnosis.

3. Spinal Stenosis:

• Risk Factors:
  Narrowing of the spinal canal or neural foramen due to conditions
  like spondylosis or spondylolisthesis.
• Pain Description:
  Leg pain more than back pain,
  worsens with standing/walking,
  improves with sitting/flexion.
• Exam Findings:
  Symptoms induced by bending backwards,
  negative SLR test,
  possible neurological findings.
• Imaging:
  MRI to confirm and rule out serious conditions.

4. Inflammatory Back Pain (Spondyloarthritis):

• Risk Factors:
  Autoimmune conditions linked to HLA-B27.
• Pain Description:
  Worse in the morning, improves with movement,
  night pain,
  morning stiffness > 30 minutes.
• Exam Findings:
  Decreased back range of motion, other joint findings.
• Imaging:
  Plain films of sacroiliac joints,
  MRI if needed.

5. Vertebral Compression Fracture:

• Risk Factors:
  Trauma,
  osteoporosis,
  prolonged corticosteroid use,
  bone metastasis.
• Pain Description:
  Varies in location and quality,
  worsened with movement.
• Age of Onset:
  Over 70 years old
• Exam Findings:
  Midline tenderness at a specific vertebral body,
  kyphosis.
• Imaging:
  Plain film of the affected spinal level.

Taking a History: What to Ask

When assessing lower back pain,
here's a handy guide for history taking (remember the acronym OPQRST):

• O: Onset
  -"When did it start?" "Did you get injured?" "Any unusual physical activity?"
• P: Provocation/Palliation
  -"What makes it better or worse?"
• Q: Quality
  -Describe the pain (sharp, dull, etc.).
• R: Radiation
  - Does the pain travel anywhere else?
• S: Severity
  - Rate your pain on a scale of 1-10.
• T: Timing
  - How long have you had it? Is it constant or intermittent?

Exam Time: Physical Examination

A thorough physical exam is crucial:

• Cardiac auscultation: If infection is suspected.
• Abdominal exam: To rule out referred pain.
• Back exam: Look for visible abnormalities, palpate, and perform the SLR test.
• Neurological exam: Check for any nerve involvement.

Labs and Imaging: When to Dig Deeper

Laboratory Tests (if infection is suspected):

• CBC, UA, blood and urine cultures.

Radiology:

• Start with X-rays.
• Move to MRI if further detail is needed or if serious pathology is suspected.

🚩 Red Flags: When to Worry

Certain symptoms and signs should prompt more urgent evaluation:
Cancer:

• Age over 50
• History of cancer
• Unexpected weight loss
• No improvement with conservative therapy
  (like physical therapy, activity modification, NSAIDs).

Infection:

• Fever
• Immunosuppression
• Focal midline tenderness
• Known or suspected bacteremia
• Indwelling venous catheter
• IV drug use

Final Notes

Lower back pain, or ぎっくり腰 as it’s known in Japan,is something many of us have experienced.

It can range from a minor nuisance to a major disruption.

Here are some common terms and phrases you might hear related to back pain:

Strained Back (Strained Muscle):
This is a common cause of lower back pain and usually not serious.

It’s often referred to as "throwing your back out" or having a "pulled muscle."

Rest, gentle stretching, and over-the-counter pain meds can often help.

Sciatica:

This term is used when pain radiates from your lower back down through your buttocks and legs, often caused by a herniated disc.

People might say they have a "pinched nerve" or feel "shooting pain" down their leg.

Herniated Disc:

Sometimes called a "slipped disc" or "ruptured disc," this occurs
when the soft cushion of tissue between the bones in your spine pushes out.

Spinal Stenosis:

This condition involves the narrowing of the spaces within your spine,which can put pressure on the nerves.

It’s sometimes referred to as having a "narrowing spine."

Degenerative Disc Disease:
This isn’t actually a disease but a term used to describe normal changes in your spinal discs as you age.

Laymen might just call it "wear and tear" on the spine.

Lumbago:

A general term for lower back pain. It’s a bit old-fashioned but still used sometimes, especially in medical contexts.

Bone Spurs:

These are bony projections that develop along the edges of bones, often where bones meet each other in your joints or along the spine.

People might call them "knobs" or "growths" on the spine.

Slipped Vertebra (Spondylolisthesis):

This happens when one of your vertebrae slips forward over the bone below it.

It’s often described as a "shifted" or "out of place" vertebra.

Facet Joint Pain:

Facet joints are small stabilizing joints located between and behind adjacent vertebrae. Pain from these joints is often referred to as "arthritis of the spine."

Layman's Tips for Dealing with Lower Back Pain:

• Heat and Ice:
  Applying heat or ice packs can help reduce pain and inflammation.
  Heat packs are often referred to as "heat wraps" or "heating pads," while ice packs can be called "cold packs" or "ice wraps."
  
• Stretching and Exercise:
  Gentle stretching and exercises can strengthen the muscles supporting your spine. Common stretches include the "cat-cow stretch," "child’s pose," and "pelvic tilts."
  
  
• Posture:
  Maintaining good posture, both sitting and standing, can prevent back pain.
  Terms like "slouching" and "hunching" are often used to describe poor posture.
  
  
• Lifting Techniques:
  Use your legs, not your back, to lift heavy objects.
  This is often referred to as "lifting with your legs" or using the "power lift" technique.
  
  
• Ergonomics:
  Setting up your workspace to support good posture can help.
  This includes using "ergonomic chairs," "standing desks," and "footrests."

Idioms and Phrases Related to Back Pain:

• "Back-breaking work":
  This phrase is used to describe extremely hard physical labor that can lead to back pain.
  
  
• "Carrying the weight of the world on your shoulders":
  This idiom means feeling overwhelmed by responsibilities, which can sometimes lead to actual back pain from stress.
  
  
• "A pain in the neck/back":
  Used metaphorically to describe something or someone very annoying or troublesome, similar to how actual back pain can feel.

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お疲れさまでした

一緒に学んできたように、誰もが経験したことのある腰痛ですが

考えなければいけないことがたくさんあって、これだけまとめていてもまだまだ足りないくらいです、、、

ですが、

しっかりマスターしておけば、自信をもって診療のできる患者さんも増えると思うので

少しずつ落とし込んでいきましょう

Lower back pain can be frustrating and debilitating,
but with the right approach and understanding, it can be managed effectively.

If you’re experiencing severe symptoms or red flags, don’t hesitate to seek professional medical advice.

Stay mindful of your posture, engage in regular exercise, and use the tips and terms above to help navigate through your back pain journey.