Back Pain

Rationale

Back pain is one of the most commonly encountered problems in the outpatient, primary care internal medicine setting. It has an important differential diagnosis, and the initial decision-making must be made on the basis of clinical findings. As such, it is an excellent training condition for teaching decision-making based on careful collection and interpretation of basic clinical data. There is emerging data on test utility, especially as regards expensive spinal imaging, which facilitates teaching rational, cost-effective test ordering. Moreover, its requirement for skillful management and patient education and support facilitate the teaching of these competencies.

Prerequisites

Prior knowledge, skills and attitudes acquired during the pre-clinical (basic science) years should include:

1. The bony, soft tissue, vascular, and neuroanatomies of the spine
2. The dermatomes corresponding to spinal roots
3. The pathophysiology of strain, osteoporosis, disc degeneration, and spinal metastasis
4. Basic physical examination of the spine
5. Basic neurologic examination of the lower extremities
6. Basic communication skills

Specific Learning Objectives

1. Knowledge: Students should be able to define and describe:
   1. the signs and symptoms of muscle strain, lumbar disc herniation, vertebral compression fracture, spinal metastasis, spinal epidural abscess, and cauda equina syndrome
   2. the clinical features that differentiate one etiology from another
   3. the role of neuroimaging studies in the evaluation of back pain, including their indications, limitations, and cost
   4. the natural history of the important causes of back pain, especially those which require urgent attention (cauda equina syndrome, epidural abscess, spinal metastasis) and those which do not (strain, minor disc herniation)
   5. response to therapy of the various etiologies, with understanding of the roles of bed rest, exercise, analgesia, anti inflammatory agents, heat, cold, ultrasound, back manipulation, and surgical interventions
   6. means of limiting disability and chronicity
   7. describe steps in a critical pathway for back pain
2. Skills: Students should demonstrate specific skills including:
   1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history that differentiates among etiologies of disease, including:
      1. elicitation of key elements of the history helpful in establishing etiology, ruling out “must-not-miss” causes, and determining degree of disability, including presence of:
      2. radicular pain
      3. focal numbness or weakness
      4. bladder or bowel dysfunction
      5. rapid progression of symptoms
      6. saddle anesthesia
      7. focal back tenderness with fever
      8. prior history of cancer
   2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease, including:
      1. straight-leg raising test
      2. assessment for:
      3. radiculopathy
      4. spinal cord compression
      5. epidural abscess (e.g., checking for saddle anesthesia, focal tenderness)
   3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology of back pain
   4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment, based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences including:
      1. laboratory tests should include, when appropriate:
      • sedimentation rate (ESR)
      • back X-rays
      • CT scan
      • MRI
      • bone scan
      • myelogram
   5. communication skills: Students should be able to:
      1. communicate the diagnosis, treatment plan, and prognosis of the disease to patients and their families
   6. basic procedural skills: None
   7. management: Students should be able to develop an appropriate evaluation and treatment plan for patients that includes:
      1. proper use of analgesics and muscle relaxants
      2. teaching back hygiene measures, proper use of bed rest and exercises, and mechanics of lifting and standing
      3. timely use of consultants in properly selected patients
      4. provision of psychological support and patient education
      5. a cost-effective approach based on the differential diagnosis, with parsimonious use of imaging tests
      6. accessing and utilizing appropriate information systems and resources to help delineate issues related to back pain
      7. patient preferences
3. Attitudes and Professional Behavior: Students should be able to:
   1. respond appropriately to a patient with chronic back pain
   2. respond to a patient who is non-compliant with recommended treatment options