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HIGH RISK BACK PAIN: MORE THAN JUST MOTRIN!. Nilesh Patel February 19, 2009 St. Joseph’s Regional Medical Center Paterson NJ. OBJECTIVES. Epidemiology Differential Red Flags High Risk Presentations Pearls & Pitfalls. EPIDEMIOLOGY. Very common chief complain in ED - PowerPoint PPT Presentation
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HIGH RISK BACK PAIN: MORE THAN
JUST MOTRIN!Nilesh Patel
February 19, 2009St. Joseph’s Regional Medical Center
Paterson NJ
OBJECTIVES Epidemiology
Differential
Red Flags
High Risk Presentations
Pearls & Pitfalls
EPIDEMIOLOGYVery common chief complain in ED
>90% benign >> will resolve in 4-6 weeks“The majority of patients who present to the ED have a non-
specific etiology that has no life or limb threatening concerns”“70-90% of all individuals will suffer back pain at some point in
their lives”
5-10% serious pathology“One can develop an indifference to this complaint and
potentially overlook serious causes of back pain”
History & Physical key to diagnosis
BACK PAIN EMERGENCIESVascular
Aortic Dissection AAA
Infectious Osteomyelitis/Diskitis Spinal epidural abscess Transverse Myelitis
Spinal Cord Compression Syndromes Cauda Equina Syndrome—malignancy, herniation Epidural Hematoma
Trauma
Malignancy
BACK PAIN EMERGENCIESPulmonary
PE
GI/GU Retroperitoneal bleed Ovarian torsion, diverticulitis, appendicitis
Renal Renal abscess Renal infarction
Neurologic Spinal cord infarction
RED FLAGSAge < 20 or > 60
Untraditional pain
Constitutional symptoms
Neuro S & S
Hx: Trauma Cancer Immunosuppression IVDA Recent instrumentation
PHYSICAL EXAMVital signs
Abdomen/GU
Back
NeuroMotorSensoryReflexesGaitRectal
CASE # 1CC:
Back pain
HPI:67 y/o maleLeft lower lumbar painAcute onsetPain sharp, moderate to severe, non-radiatingPositive SOB
CASE # 1PMHx/PSHx:
Severe COPD, HTN
Meds:Spiriva, Norvasc
Alleriges:NKDA
SHx:Former heavy tobacco use. No alcohol or drugs. No IVDA
CASE # 1Review of Systems—positive back pain, sob, cough
VS-- 105/58, 120, 20, 96.4, 96% on 3 L
Gen-- AAO, in moderate respiratory distress
CVS-- RRR, tachy, no murmurs
Lungs-- b/l very diminished breath sounds, no W/R/R
Abd-- soft, nontender, normal bowel sounds, no masses
Back-- mild tenderness L flank, no vertebral point tenderness
Neuro-- nonfocal
CASE # 1 14.3 Neutrophils 80%
21.4 153 Bands 0
43.0 Cardiac enzymes negative
137 100 20 UA negative
199 EKG sinus tachycardia
4.3 22 1.1
ED COURSE11:02 pm…Pt presented to ER via EMS and had initial VS
105/58 120 20 96.4 96% on 3 LPain level 6/10
11:18 pm…Pt. evaluated by ER physicianAlbuterol 10 mg/Atrovent 1 mg neb, Solumedrol 125 mg IV,
Morphine 2 mg IV, NSS 500 cc bolus
1:00 am…108/80 100 20 98% on 2 LPain level 5/10
CT scan a/p without contrast ordered
ED/HOSPITAL COURSE1:30 am
73/52 112 24 97% on 3 L
Vascular surgery urgently consulted
PRBCs ordered
Pt went to OR
7:30 am…Surgery completed, pt received several units of blood
Pt. expired in SICU shortly after surgery
RUPTURED AAA
EPIDEMIOLOGYIncidence 36.2 cases/100,000
Increased incidence with aging
Increased incidence in Caucasians
5-10% patients age 60-80 will have AAA
15,000 deaths/year
Very high mortality with rupture
NATURAL HXRisk of rupture increases with size of aneurysm
Average expansion rate 0.4 cm/year
Aneurysms > 5-6 cm expand more rapidly
Surgical threshold 5-6 cm
PATHOGENESISAtherosclerosis…Familial
Infra-renal
Risk FactorsTobacco useAge > 60HTNAtherosclerosisFamily HxMale genderCOPD
CLINICAL FEATURESTRIAD
Hypotension
Abdominal Pain/Back pain
Pulsatile abdominal mass
CLINICAL FEATURESAbdominal pain
Back pain/flank pain
Syncope
Vomiting
SOB
Weakness
Groin pain
VS abnormalities
Pulsatile abdominal mass
Abdominal bruit
Peripheral embolic events
Pulse deficits
DIAGNOSTICSClinical
UltrasoundSensitivity 95-100%ED Ultrasound!
CT scanSensitivity/Specificity close to 100%
TREATMENTED
ABC IV/O2/Monitor IVFPRBCsUrgent vascular surgery consult
DefinitiveSurgery
CASE # 2CC:
Back pain
HPI:52 y/o maleLower right sided back painStarted 5 days ago and worseningConstant pain, radiates to R hip/groin/abdomenWorsened by movementSeen in ER 3 days ago and discharged on pain meds
CASE # 2PMHx/PSHx, Meds, Allergies:
None
SHx:Denied tobacco/alcohol useFormer IV heroin use, quit 8 months ago
ROS positives:Fever/ChillsAbdominal painBack painUrinary frequencyWeakness
CASE # 2VS-- 102/70 100 20 98.0 100% RA
Gen-- AAO times three, in moderate discomfort
Abd-- soft, mild tenderness rlq, suprapubic area
Back-- tenderness L3-L5, R CVA tenderness, pain with any range of motion
Neuro-- 4/5 motor LE bilaterally (? due to pain); 5/5 motor UE b/l
ED COURSEToradol, Percocet
UA—moderate blood (5-9 rbc), no LE or WBC
CT a/p without contrast negative
Upon discharge, pt still with pain
Temp 103.5
CASE # 2 14 Neutrophils 80%
23.3 156 Bands 11%
43 ESR 59
135 95 21 CT--? Inflammatory changes
186 anterior to L5-S1
4.2 25 1.7
ED COURSEAdmit
Vancomycin IV
MRIOsteomyelitis involving L4, L5Spinal epidural abscess causing mass effect on cauda equina
Blood Cultures2/2 MRSA
SPINAL EPIDURAL ABSCESS
EPIDEMIOLOGY0.2-1.2 cases/10,000 hospital admissions
Rare
High morbidity
PATHOGENESISHematogenous spread
Direct Innoculation
Spread from contiguous site
Idiopathic
Staph aureus (MRSA)– 2/3 cases
Staph sp.
Gram negatives (E. coli, Pseudomonas)
RISK FACTORSUnderlying disease
IVDA
Recent instrumentation
Indwelling catheters
Contiguous/hematogenous spread
CLINICAL FEATURESTRIAD
Back pain
Fever
Neurologic deficit
CLINICAL FEATURESJournal of EM 2004
63 patients
SymptomsBack pain—95%Radicular pain—62%Neuro deficit—41%Fever—33%Triad—8%
CLINICAL FEATURES98% had at least one risk factor
68%--multiple ER visits
75%--diagnostic delay
45%--neuro deficit due to delay
62%--concurrent osteomyelitis
37%--concurrent diskitis
Take Home Points…
DIAGNOSTICSCBC, ESR,CRP, Blood Cultures
MRIDiagnostic test of choice
X-ray
CT myelography
Bone Scan
CT scan
TREATMENTED
ABCs IV antibioticsUrgent neurosurgical consultation
Definitive IV antibioticsCT-guided needle aspirationSurgical drainage
OSTEOMYELITIS/DISKITIS
EPIDEMIOLOGY/PATHOGENESIS
Risk factors similar to SEASickle cell disease
MicrobiologyStaph aureus leading causeOther Staph sp.Gram negativesPolymicrobialTBFungal
CLINICAL FEATURESAcute/subacute/chronic
Back pain
Fever
Systemic symptoms
Cellulitis
DIAGNOSTICSCBC, ESR, CRP, Blood cultures
X-ray
Bone scan
CT, MRI
Needle biopsy/bone biopsy
TREATMENTIV antibiotics (prolonged treatment)
Surgical debridement
CASE # 3CC:
Weakness
HPI:78 y/o maleWeakness over past 1 week, progressively worseningWeakness pronounce in LE, unable to ambulateBack painFecal incontinence
CASE # 3PMHx/PSHx, Meds, Allergies, SHx:
None
ROS positives:WeaknessNumbnessUrinary incontinenceFecal incontinence
CASE # 3VS-- 165/90 115 24 99.2 98% RA
Gen-- AAO times three, anxious
CVS-- RRR, tachy, no murmurs
Neuro-- 2/5 motor LE b/l, no sensation in LE, reflexes absent; UE motor, sensation preserved
Rectal-- loss of tone, enlarged firm prostate
CASE # 3 9.2 PT 13.5
15.5 125 INR 1.2
132 105 25 UA 5-9 WBC, 0-5 RBC
154
4.4 20 1.4
ED COURSEMRI
Spinal cord compression consistent with cauda equinaDestructive bony lesions lumbar vertebra consistent with
metastatic disease
Transferred to MICU, neurosurgery consult
Prostate CA with bony metastasis
SC COMPRESSION SYNDROMES
Malignancy--mets
Central disk herniation
Epidural hematoma
SEA
Trauma
Transverse myelitis
EPIDEMIOLOGYPrevalence low back pain patients 4/10,000
Most common in 4th-5th decades
Male predominance
PATHOGENESISCompression of conus medullaris or nerve roots of cauda
equina
Disk herniation
Malignancy
L4-L5
EXAM NORMALSMotor
L1-L2…hip flexion
L3…hip adduction
L4…hip abduction
L5…foot dorsiflexion
S1-S2…foot plantar flexion
S2-S4…rectal tone
Reflexes
L4….patellar
S1…ankle
CLINICAL FEATURESTRIAD
LE weakness
Saddle anesthesia
Loss of bowel/bladder function
CLINICAL FEATURES (AJEM March 2004)
Low back pain
Radicular symptoms
LE paresthesias
LE weakness
Urinary/fecal retention
Urinary/fecal incontinence
Gait abnormalities
LE motor weakness
Saddle anesthesia
Decreased/absent DTR’s
Decreased/absent sphincter tone
Post void residual
DIAGNOSTICSClinical diagnosis!
X-ray
MRIGold standard for diagnosis
CT myelography
TREATMENTED
ABCs IV steroids (high dose)Pain controlUrgent neurosurgery consultation
DefinitiveEarly surgical intervention
MALIGNANCYMost common cause of spinal cord compression syndromes
Usually metastaticBreast, Prostate, LungKidney, Thyroid, Colorectal, Non-Hodgkin’s, MM
DiagnosticsX-ray, CT, MRI
ManagementUrgent neurosurgery consultRadiation-onc consult—localized radiotherapy IV steroidsHypercalcemia
PEARLS & PITFALLSPearls
Assess for red flags—history & physical examKeep high risk diagnoses in mind—DDx
PitfallsChronic back painPerception of drug-seeking behaviorsSevere pain—incomplete evaluationBounce-back patients
SUMMARYRed Flags in history…Risk Factors
Physical Exam—Vital signs, Back, Neuro
DDx
AAA
SEA
Osteo
Cauda equina
Malignancy