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Back Pain

back symptoms are the most common cause of disability in patients under 45 years of age

approximately 1 % of the U.S. populations chronically disabled because of back pain

Type of back pain

Local pain

stretching of pain-sensitive structures that compress or irritate sensory nerve ending

pain referred to the back

may arise from abdomen, pelvic viscera

usually affected by posture

pain of spine origin

referred to the buttock or legs

rarely calves or feet

radicular back pain

typically sharp and radiates from the spine to the leg

Patient Problem

Lumbosacral radiculopathy

HTN

Asthma: long time ago

Hysterectomy X 20 years

Lumbosacral Radiculopathy

Chief complain

pain in left buttock

pain in the back of left leg

pain radiated to the ankle

numbness and paresthesia in the left foot

PE: muscular

weakness at left big toe, left leg, strength limited by pain

MRI and radiology

large herniated disc impairing on left L5, S1

not present in 1998 study

Lumbosacral Radiculopathy(cont.)

Other laboratory studies

EMG

assess the functional information about motor nerve fiber injury

Plain films of the lumbar or cervical spine

helpful when

absence of risk factors

routine x-rays of the lumbar sine in the setting of acute, nonspecific, lower back pain

MRI and CT

radiological tests of choice for evaluate of most serious diseases involving the spine

Lumbosacral Radiculopathy(cont.)

Lumbosacral radiculopathy-neurologic features

Nerve root Pain distibution

L5 lateral calf, dorsal foot, posterolateral thigh, buttocks

S1 bottom foot, posterior calf, posterior high, buttocks

Lumbosacral Radiculopathy(cont.)

Pharmacotherapeutic goal

alleviate pain

increase quality of life

minimized toxicity from medications

decrease risk for fall

symptom free survival

Lumbosacral Radiculopathy(cont.)

Recommendation for therapy (in hospital)

Dexamethasone 2 mg q8 hours

Percodan 1 tab q6 hours prn

Toradol 30 mg qd

Lovenox 30 mg qd SQ

Lumbosacral Radiculopathy(cont.)

Monitoring

vital sign: qd

CBC and Chemistry: weekly in the hospital, every 3 month upon discharge

Pain scale: 2 times daily

medication

dexamethasone

Percodan

Toradol

Lovenox

Lumbosacral Radiculopathy(cont.)

Dexamethasone

PO, aerosol, ophthalmic, IV

MOA

decrease inflammation by suppression of migration of polymorphonuclear leukocytes and in reversal of increased capillary permeability

suppresses normal immune response

SE

increase appetite, insomnia, hirsutism, moon face

Lumbosacral Radiculopathy(cont.)

Percodan (oxycodone and aspirin)

PO

MOA

bind to opiate receptors in the CNS, causing inhibition of ascending pain pathways, altering the perception and response to pain,produces generalized CNS depression

SE

hypotension, drowsiness, weakness, nervousness

Lumbosacral Radiculopathy(cont.)

Toradol (ketorolac)

IV, PO, ophthalmic solution

short term (5 days)management of pain

MOA

inhibits prostaglandin synthesis by decreasing the activity of the enzyme, cyclo-oxygenase, which results in decreased formation of prostaglandin precursors

SE

edema, drowsiness, dyspepsia

Lumbosacral Radiculopathy(cont.)

Lovenox

IV

MOA

enhancing the inhibition rate of clotting proteases by antithrombin III impairing normal hemostasis and inhibition of factor Xa.

SE

pain at injection site, erythema, bruising, hemorrhage

Lumbosacral Radiculopathy(cont.)

Other treatment option

Physical therapy

beneficial for more than 50% of patient

patient education

prognosis, treatment methods activity modifications, strategies to prevent future exacerbations

Medication

acetaminophen

muscle relaxant

short term benefit (4-7 days)

Hypertension (cont.)

Pharmacotherapeutic goal

to control BP (120/80), PR (72-80)

increase quality of life

minimize side effect from medications

Decrease hypotensive event

Minimized complications

Hypertension (cont.)

Recommendation for therapy

Metoprolol 100 mg bid

Cardizem CD 240 mg qd

Hypertension (cont.)

Monitoring parameters

vital sign: qd

CBC and chemistry: 3-4 times yearly

medication

Metoprolol

Cardizem

Hypertension (cont.)

Metoprolol

IV, PO

MOA

selective inhibitor of B-adrenergic receptors, competitively blocks B1-receptor, with little or no effect on B2-receptor at <100mg.

SE

fatigue/dizziness, bradycardia, arrhythmia

Hypertension (cont.)

Cardizem

IV, PO

MOA

inhibit calcium ion from entering the "slow channels" or select voltage-sensitive areas of vascular smooth muscle and myocardium during depolarization, producing a relaxation of coronary vascular smooth muscle and coronary vasodilation; increase myocardial oxygen delivery in patient with vasospastic angina

SE

bradycardia, EKG abnormality,flushing, headache, peripheral edema