HY lecture notes:
Back pain worse in the morning and gets better throughout day in male 20s-40s –> ankylosing spondylitis.
Bamboo spine –> ankylosing spondylitis.
Dx of AS –> x-ray of sacroiliac joints.
HLA-B27 associations –> PAIR –> Psoriasis, Ankylosing spondylitis, IBD, Psoriasis.
Blood in stool in guy with ankylosing spondylitis –> likely IBD (HLA-B27 association).
Lower back pain in someone with psoriasis –> likely sacroiliitis (usually first Sx of ankylosing spondylitis).
Back pain worse when standing or walking for long periods of time –> lumbar spinal stenosis.
Back pain worse when walking down a hill –> lumbar spinal stenosis.
Radiculopathy down an arm –> cervical disc herniation.
Radiculopathy down a leg –> lumbosacral disc herniation.
24M lifts a heavy box + gets lower back pain with paraspinal muscle spasm + positive straight-leg raise test + no radiating pain; next best step in Mx? –> answer = no further studies indicated; x-ray is the wrong answer here.
Straight-leg raise test should ordinarily be positive in sciatica, but the test is not very reliable and has false-positives.
For simple lumbosacral strain, do not x-ray. Tx is exercise as tolerated + NSAIDs if necessary. Bed rest is the wrong answer for Tx.
24M lifts a heavy box + gets lower back pain that radiates down a leg; next best step in Mx? –> x-ray –> in this case, we think about disc herniation. Although x-ray does not detect the herniation, it’s still the next best step before MRI in order to rule out other things like vertebral mal-alignments.
Bilateral paresthesias in the arms in rheumatoid arthritis patient –> atlantoaxial subluxation.
Bilateral paresthesias in the arms in rheumatoid arthritis patient –> MR of spine to Dx atlantoaxial subluxation.
Prior to surgery in rheumatoid arthritis patient –> cervical CT or flexion/extension x-rays of cervical spine to check for atlantoaxial subluxation.
Back pain in elderly patient with hypercalcemia –> multiple myeloma or metastases.
Back in pain in patient with history of other type of cancer –> metastases.
Suspected spinal mets –> MRI.
Metastases to long bones in prostate cancer –> osteoblastic (Dx with bone scan); spine do MRI.
Bell palsy; next best step in Mx? –> “no further studies indicated” –> the wrong answer is “nerve conduction studies.”
