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Lower back pain

Lower back pain. Pete, Andy and Jackie . Presentation. 65 y.o . man with lower back pain 3 day history, pain comes and goes Sharp, burning pain. Like “electric shock”. Can be severe Left side only Radiates to flank, sometimes to abdomen Unrelated to activity

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Lower back pain

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  1. Lower back pain Pete, Andy and Jackie

  2. Presentation • 65 y.o. man with lower back pain • 3 day history, pain comes and goes • Sharp, burning pain. Like “electric shock”. • Can be severe • Left side only • Radiates to flank, sometimes to abdomen • Unrelated to activity • Q1  What further history do you require ?

  3. Seems neural. Shingles? Impingement? • Previous back pain? • Neural review • Neck stiffness, vision, hearing, balance, tingling/numbness, tics, tremors, weakness, bowel and bladder changes • Systems review • Fever, sweats, weight changes, cough, dysphagia, palpitations, SOB, chest pain • PMHx • Chicken pox when young • Cancers (also FHx) • Recent illness, fever • PSHx • Surgery or trauma to back, neck, or head • Meds • Painkillers • Corticosteroids • Social Hx • Occupation, hobbies, exercise, stress • Change in sleeping conditions? New mattress? • Other changes? New shoes? New car?

  4. More History • No injury to his back • No history of back problems  • Denies fever • Denies urinary symptoms • Denies gastrointestinal symptoms.Q2 Detail your proposed examination.

  5. Examination • Body temp • Gross neural • Gait, hand strength, pupils, fundoscopy, mental state • At level of pain: • Which dermatome/s • Skin changes – rash, scar, swelling, color, temperature • Palpation – spinous processes, laminae, musculature • Sensation – touch, pain, vibration • Lower limb neural exam

  6. Trigger 3 • Examination is normal • Prescribe NSAIDs • Patient returns complaining of an allergic reaction to meds – rash • Rash – located in area where pain was, • eruption consisting of patches of erythema with clusters of vesicles extending a dermatomal distribution from left lower back to midline of abdomen • What is your diagnosis? • And what is the cause of the rash?

  7. SHINGLES!!! • Caused by varicella-zoster virus

  8. What is the mechanism for the dermatomal distribution of the rash? • Varicella-zoster virus (VZV) lies dormant in the spinal dorsal root ganglia until a decrease in cellular immunity triggers the reactivation of the virus • VZV reactivation causes inflammation in the dorsal root ganglion, accompanied by hemorrhagic necrosis of nerve cells. The result is neuronal loss and fibrosis. • The distribution of the rash corresponds to the sensory fields of the infected neurons within a specific ganglion. The anatomic location of the involved dermatome often determines the specific manifestation

  9. Discuss a general management plan for this patient. • Rash usually resolves within 10-15 days • Prognosis good for young and otherwise healthy patients • Elderly patients have a significantly higher risk of complications including postherpetic neuralgia, bacterial infections and scarring TREATMENT • Antiviral treatment should be commenced in any patient within 72 hours of the onset of vesicles, all patients with herpes zoster ophthalmicus and in immunocompromised patients • Famciclovir • Valaciclovir • Aciclovir • For 7 days, or 10 for immunocompromised. • Early therapy has been shown to reduce both early and late-onset pain, especially in patients over 65 (reduces pain by 10 days and risk of post-herpetic neuralgia by 8%)

  10. List two (or 3) possible complications of this presentation. • Postherpetic neuralgia • pain that persists for longer than 1 month following resolution of the vesicular rash. • incidence increases dramatically with age (ie, 3-4% in those aged 30-50 y; 34% in those >80 y) • Treated with analgesics, TCA, gabapentin, possibly opioids or topical lignocaine • Herpes zoster ophthalmicus(occurs in 10-25% of shingles cases) • Results from reactivation of HZV in trigeminal gangli, can lead to: • Chronic ocular inflammation • Visual loss • Debilitating pain • Ramsay Hunt syndrome • Also known as herpes zoster oticus, geniculate neuralgia, or herpes zoster auricularis, • Caused by VZV reactivation involving the facial and auditory nerves • Vesicular eruptions may manifest on the pinna, tragus, or tympanic membrane or in the auditory canal, as well as anywhere in the facial nerve distribution. • The patient may experience • hearing impairment • nystagmus • vertigo or • facial nerve palsy (mimicking Bell palsy). • Patients may lose taste sensation in the anterior two thirds of the tongue.

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