On 8/22 Dr. Pierro presented an interesting case of subacute low back pain with cord compression. The final diagnosis was lymphoma as the etiology of cord compression.
Some take home points include the following...
1. The most common cause of acute back pain is "nonspecific back pain". It encompasses 85% of patients who present to clinic with acute back pain. It is most commonly due to lumbar sprain, degenerative disk disease, etc.
-> The prognosis of acute low back pain due to "nonspecific back pain" is excellent. Most patients will see improvement in symptoms with conservative measures and time.
-> Your history and physical exam can help to evaluate for other more serious back pain etiologies. These include: spinal stenosis, disk herniation, compression fracture, ankylosing spondylitis, infection (epidural abscess, osteomyelitis), and malignancy/mass. Some of these serious etiologies can cause acute spinal cord compression or cauda equina syndrome, a neurological emergency.
-> The most common causes of cord compression include: disk herniation (23%), ankylosing spondylitis (16%), post lumbar puncture (16%), trauma sequelae, tumor (12%), infection (5%).
2. Dr. Pierro summarized the ACP/APS Practice Guideline for LBP (2007).
-> The table below created by Dr. Pierro nicely summarizes the imaging recommendations for low back pain, as outlined in the practice guideline.
3. Finally, we discussed eligibility for pre-exposure prophylaxis (PrEP) for HIV infection. Your patient may be eligible for PrEP if they meet the following criteria.
-> Recent documentation of negative HIV test
-> GFR >60 mL/min/1.73m2
-> Patient plans to adhere to medication
-> Patient has substantial risk for acquiring HIV*
*HIV uninfected man/woman with partner with a detectable viral load, MSM or transgender woman who has sex w/ men if they engage in high risk sexual behaviors (condom-less anal sex with multiple partners) or have history of recent STI, heterosexual man who has condom-less sex w/ female partners in HIV epidemic areas (prevalence >3%), injection drug users who within last 6 months report needle sharing.
-----> To start PrEP, prescribe 1 tab of emtricitabine / tenofovir daily. Follow HIV ab testing q3 months and creatinine q6 months. Continue to council on condom use, risk reduction, and medication adherence.
-----> PrEP is effective! It can reduce rate of HIV by 90% in high risk patients.
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