Episode 48 - Acute Low Back Pain - a podcast by Rio Bravo Family Medicine Residency Program

Episode 48: Acute Low Back Pain. 

Stephanie and Veronica explain common causes of acute low back pain, including lumbar strain, disc herniation, and spondylosis; spontaneous human combustion; question of the month about pneumonia. 

Introduction: Spontaneous Human Combustion
By Hector Arreaza, MD

Today is April 19, 2021.  

I’ve been trying to keep this podcast very academic and clinically relevant, with a touch of humor but very professional. I hope after this intro, you do not stop listening to us. 

Recently I was playing a trivia game at a friend’s house. The question was: How many spontaneous human combustion cases have been published in medical journals between 1600 and 1900? What would be your answer? I did not know the answer, but it woke up my curiosity.

I did what’s expected of a normal PCP, exactly, I looked it up in Up-to-Date. The only reference to “spontaneous combustion”, I found was on the article about long-term supplemental oxygen therapy (LTOT). “Facial and upper airway burns are an infrequent complication of LTOT, but can be severe and potentially life-threatening. The main cause of burns is exposure to open flames while wearing supplemental oxygen. However, spontaneous combustion may occur with exposure to a spark source rather than an open flame. Certain factors may contribute to the risk of combustion in the absence of open flames, such as facial hair and use of hair products containing oils or alcohol.” This “spontaneous combustion” does not match the definition given the non-medical community.

Spontaneous human combustion, also known as preternatural combustion, refers to a rare episode where the complete body, or significant parts of it, are reduced to ashes with no apparent source of ignition. Other items around the body of the victim are intact, making people believe that the fire originated from inside the body. This phenomenon has been described in fictional movies, documentaries, books, novels, and even medical journals. 

In 1984, Nickell and Fischer[3] investigated cases from the last 3 centuries. They concluded that in those cases of presumed “spontaneous human combustion” possible sources of ignition were ignored on the reports. A common characteristic among victims of spontaneous combustion was intoxication with alcohol or other substances.

More recently, the American Burn Association looked into this topic and published in 2012[2] an article titled “Spontaneous Human Combustion in the Light of the 21st Century”. They state that a literature search retrieved 12 case reports between 2000 and 2012. They concluded that the so-call “spontaneous human combustion” is a reality, however, it is not exactly how people think it is. People are not just sitting around and get consumed alive in flames. The term “fat wick burns” was suggested to provide a more exact definition. The article explains that the burn victim must die for the body fat to start melting, then a break in the skin allows melted fat to impregnate clothes and produce a wick effect that allows fire to be on for a long time causing a complete carbonization of tissues. 

In case you are curious, the number of spontaneous human combustion cases published in medical journals between 1600 and 1900 is ninety-six (96). Citation needed.

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

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Question of the Month: Cough and Fever
Written by Hector Arreaza, MD, read by Jacqueline Uy, MD

This is a 69-yo male patient, who has history of controlled hypertension. He comes to an urgent care clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. He does NOT smoke, but uses recreational marijuana once a month, and drinks 1-2 beers a week. He goes to the doctor once a year for check-ups. He takes benazepril 10 mg daily for his hypertension. He does not believe in vaccines and his last shot was a tetanus shot 5 years ago. No surgical history. He retired as an accountant 5 years ago. Vital signs are normal except for tachycardia of 110 (his baseline is 85) and temperature of 101.5 F (38.6 C). He has bibasilar crackles on auscultation. You perform labs in clinic and he has a white count of 13.5, and a chest x-ray shows a right lower lobe consolidation. He has a negative rapid COVID-19 test. 

What are your top 3 differential diagnoses and what is the acute management of this patient’s condition?

Let’s repeat the question: What are your top 3 differential diagnoses and what is the acute management of a 69-year-old male, non-smoker, who has fever, cough, shortness of breath, tachycardia, bibasilar crackles, elevated WBCs, a right lower lobe consolidation, and a negative rapid COVID-19 test?

Send us your answer before May 7, 2021, to rbresidency@clinicasierravista.org and the best answer will win a prize!

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Acute Low Back Pain. 

By Stephanie Rubio, MS3, and Veronica Phung, MS3.

 

Acute low back pain definition and statistics. 

 

Eighty percent (80%) of Americans will experience back pain at some point in their lifetime.  Low back pain is the 5th most common reason for all doctor visits in the US. Most cases of low back pain are acute and 90% resolve within 1 month. Recurrence rate for back pain is high at 35% to 75%. 

 

Acute back pain is defined as pain in the lumbar area for less than 3 months. The sources of low back pain are extensive. We would like to discuss some of the more common causes and important considerations when a patient presents with acute low back pain. 

 

With such an extensive differential for acute low back pain, we want to briefly discuss three common causes: lumbar strain, disc herniation, and degenerative arthritis of the spine; AND three causes that require special attention: cauda equina, malignancy, and prostatitis.  

 

 

 

Lumbar strain

Lumbar strain is the most common cause of acute low back pain in adults. Presentation can be acute or sub-acute after an injury or strenuous activity such as moving heavy furniture. Paraspinal muscles are typically the source of pain and can be unilateral or bilateral with or without radiation down the leg. Pain increases after immobility and specific movements depending on strain location. Patient will have a negative straight leg test. 

 

Treatment: Patient education is key for treatment. It includes explaining that acute back pain is often benign in nature and reassurance. Advise your patients to stay active; to avoid twisting and bending, particularly when lifting; and to return to normal activities as soon as possible. 

 

NSAIDs or muscle relaxants will help the pain process. Muscle relaxants combined with NSAIDs may have additive benefit for reducing pain. “Moderate evidence suggests that no one NSAID is superior, and switching to a different NSAID may be considered if the first is ineffective.” In clinic: Ibuprofen and Naproxen are our “go-to” medications. Acetaminophen is also an option. 

 

“Moderate-quality evidence supports that non-benzodiazepine muscle relaxants (such as cyclobenzaprine, tizanidine, and metaxalone) are beneficial in the treatment of acute low back pain in the first seven to 14 days with effects for up to 28 days. However, muscle relaxants do not affect disability status. Make sure you warn your patient about drowsiness, dizziness, and nausea. Diazepam and Soma (carisoprodol) have the potential for abuse, so use them cautiously and for a short period only. 

 

We also have to mention the controversial opioids. Due to the opioid epidemic, prescribe opioids only for patients with severe acute low back pain for a short period; however, there is little evidence of benefit when compared to NSAIDs. 

 

Epidural steroid injections are not so beneficial for isolated acute low back pain, they may be helpful for radicular pain that does not respond to two to six weeks of noninvasive treatment. Transforaminal injections appear to have more favorable short- and long-term benefit than traditional interlaminar injections. Ok, we are done with lumbar strain.

 

Disc herniation
Disc herniation may also be acute or subacute with a variety of pathologies involving the displacement of disc material into the spinal cord or nerve roots. 

Presentation: Sudden injury could precipitate pain such as a sharp, burning, stabbing pain radiating down the posterior or lateral aspect of the leg and it is made worse when hips are flexed such as sitting. 

Radicular pain in the dermatome of the compressed nerve root is common. Herniation at L5-S1 is the most common location, and it would present as a loss of sensation on the dorsolateral thigh, lower leg, and dorsal foot. 

Patients can also have motor deficits on the lateral side of the foot which can cause a problem in tilting the sole of the foot away from the midline or difficulty toe walking. Use neurologic deficits to determine the location of herniation.

Radicular pain and radiculopathy are not the same. Radicular pain is a single symptom (pain) that follows the distribution of a nerve root. Radiculopathy is a group of symptoms including, paresthesia, hypoesthesia, motor dysfunction and pain. Symptoms may be the result of compression of more than one nerve root.

Nerve Root	Dermatomal area	Myotomal area	Reflexive changes
L1	Inguinal region	Hip flexors
L2	Anterior mid-thigh	Hip flexors
L3	Distal anterior thigh	Hip flexors and knee extensors	Diminished or absent patellar reflex
L4	Medial lower leg/foot	Knee extensors and ankle dorsiflexors	Diminished or absent patellar reflex
L5	Lateral leg/foot	Hallux extension and ankle plantar flexors	Diminished or absent Achilles reflex
S1	Lateral side of foot	Ankle plantar flexors and evertors	Diminished or absent Achilles reflex

(Source: Physio-pedia.com, https://www.physio-pedia.com/Lumbar_Radiculopathy)  

Treatment: Please tell patients to keep moving as much as possible. Bed rest is not helpful and may prolong the pain process. NSAIDs should be used to decrease inflammation. Neurosurgery consultation may be needed for large herniation, especially if there is spinal canal compression, causing severe or progressive motor deficit. 

Use of steroids may be beneficial, but the available evidence suggests limited or no benefit. I’ve seen prednisone prescribed by neurosurgeons frequently when surgery is being delayed. If used, prednisone (60 to 80 mg daily) for five to seven days for patients who do not respond well to analgesics and activity modification. This is followed by a rapid taper to discontinuation over the following 7 to 14 days.

Degenerative arthritis
Spondylosis is more common in patients with advanced age. Osteophyte impingement of a nerve root can cause radicular symptoms following the nerve’s dermatome distribution as well. 

Presentation: Onset tends to be more insidious and posture dependent. For example, extension of the lumbar spine, like standing or walking upright causes pain. Symptoms are related to posture, patient may mention leaning on the shopping cart alleviates the pain.

Neurogenic claudication is typical of spinal stenosis: pain, numbness, tingling, cramping, weakness of the lower back and extremities; which are exacerbated by walking or exertion, worse walking downhill, not worsened by biking. Neurogenic claudication is not to be confused with vascular intermittent claudication, which is pain, cramping, and tightness on the lower extremities relieved by rest, NOT relieved by walking flexed with a shopping cart. 

Treatment: Conservative physical therapy is an appropriate treatment. Cycling exercises can be recommended to keep your patients moving because hip flexed activities do not induce pain. 

 

Consider a pain management clinic referral for treatment of foraminal stenosis with steroid injections. From personal experience, I can tell you, those shots really work! However, the response is not 100% effective in all patients. You do not send patients to pain management just because they are requesting chronic opioids. You send them for real treatment of pain with procedures. 

Cauda equina syndrome: This condition should always be considered due to the seriousness of the consequences. Symptoms may present as saddle anesthesia, loss of anal sphincter tone, and major motor weakness. Decompression should be performed within 72 hours to avoid permanent damage. Clinical suspicion is low if patient denies problems with bowel or bladder control. The most common symptom is actually neurogenic bladder, evidenced by acute urinary retention or incontinence.  

Malignancy: Cancer is a serious cause of back pain. Your patient may complain of a dull, throbbing pain that progresses slowly and increases with recumbency or cough. Non-radiating pain is worse at night. More common in patients over 50 and history of cancer in the past.

Genital organs: 

Prostatitis can cause referred low back pain. Expect to find evidence of infection in the history. So, a prostate exam and a genital exam may be needed in older males with acute or chronic low back pain. 

 

Females may also have referred low back pain in the setting of pelvic inflammatory disease and endometriosis. So, a pelvic exam may be needed, based on your clinical judgment.   

 

 

Overview of Acute Low Back Pain:  

 

Patients with acute LBP without any red flags such as: infections, fever, or weight loss should start conservative therapy for up to 6 weeks with NSAIDS and/or muscle relaxants. Localized cold therapy for direct injury first to constrict blood vessels, reduce swelling, decrease inflammation and potentiate a numbing effect. Then heat therapy can be used after inflammation has subsided. 

Reevaluate in 1-3 weeks, if significant pain or neurologic complications persist or if there is no improvement in pain. If there is spinal pathology detected, then surgical evaluation is needed. 

Advise patients to stay active. Physical therapy may prevent recurrence. Studies showed that early physical therapy, after primary care consultation was associated with reduced risk of subsequent health care compared with delayed physical therapy. However, it is still unclear which patients with LBP should get referred to physical therapy.

Depending on severity of pain and presentation of the patient, diagnostic studies such as MRI and labs can be ordered if findings are suggestive of serious pathology, such as bilateral radicular signs, urinary retention, saddle anesthesia or suspicion of a high-risk mechanism (cancer, hematoma, abscess), presence of fever, night sweats, nocturnal pain, older patients, and more.

For prevention, remember proper lifting techniques should be used when moving heavy objects. Bend at the knees with a straight back and use the leg muscles to lift instead of bending at the waist to prevent injury. 

Maintaining a healthy weight is important for back health.

Back-strengthening and stretching exercises at least 2 days a week help prevent back pain. exercise by using the proper equipment and techniques. Remember motion is lotion. Encourage patients to keep moving even as patients progress in age. Because you know you’re getting old when your back goes out more than you do.

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Conclusion: Now we conclude our episode number 48 “Acute Low Back Pain”. Veronica and Stephanie did a great job explaining three common causes: Lumbar strain, disc herniation, and spondylosis. Be aware of signs of cauda equine syndrome, malignancy and prostate in men and pelvic organs in women. Initial imaging and labs are not needed in most patients, but make sure to order an MRI and labs depending on the presence of red flags. 

Don’t forget to send us your answer to the question of the month: What are your top 3 differential diagnoses and explain the acute management of a 69-year-old male with fever, cough, tachycardia, right lower lobe consolidation, and negative COVID-19 test.

Remember, even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Stephanie Garcia, Veronica Phung, and Jacqueline Uy. Audio edition: Suraj Amrutia. See you next week! 

 

 

References:

Tiep, Brian L, MD; Rick Carter, PhD, MBA; Long-term supplemental oxygen therapy, Up-to-Date, Last updated: May 08, 2019. https://www.uptodate.com/contents/long-term-supplemental-oxygen-therapy. Accessed on March 25, 2021. 

 

Virve Koljonen, MD, PhD, Nicolas Kluger, MD, Spontaneous Human Combustion in the Light of the 21st Century, Journal of Burn Care & Research, Volume 33, Issue 3, May-June 2012, Pages e102–e108, https://doi.org/10.1097/BCR.0b013e318239c5d7

 

Nickell, Joe; Fischer, John F. (March 1984). "Spontaneous Human Combustion". The Fire and Arson Investigator. 34 (3).

 

Casazza BA. Diagnosis and treatment of acute low back pain. Am Fam Physician. 2012 Feb 15;85(4):343-50. PMID: 22335313. https://www.aafp.org/afp/2012/0215/p343.html.

 

Lumbar Radiculopathy, Physiopedia, https://www.physio-pedia.com/Lumbar_Radiculopathy, accessed on April 9, 2021. 

 

Fritz JM, Childs JD, Wainner RS, Flynn TW. Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine (Phila Pa 1976). 2012 Dec 1;37(25):2114-21. doi: 10.1097/BRS.0b013e31825d32f5. PMID: 22614792. https://pubmed.ncbi.nlm.nih.gov/22614792/  

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