back pain. introduction definitions history with red flags physical examination with red flags...

Back Pain

Introduction

• Definitions• History with red

flags• Physical

Examination with red flags

• Diagnostic testing• Treatment

• Sciatica and Back Pain

• Epidural Compression Syndrome

• Vertebral Osteomyelitis

• Back Pain in the Cancer Patient

Definitions

• Low back pain: pain located between the lower rib cage and the gluteal folds– Extending or radiating into the thighs

• Acute: lasting less than six weeks

• Subacute: lasting between 6 and 12 weeks

• Chronic: lasting longer than 12 weeks

History Is Key!

Red Flags

• Less than 18 yrs of age• More than 50 yrs of age• Trauma (even minor if patient is

elderly or taking steroids chronically)

• Cancer• Fever, chills, night sweats• Weight loss

Red Flags

• Injection drug use• Compromised immunity• Recent GI or GU procedure• Pain at night• Pain radiating below knee• Pain with prolonged sitting,

coughing, or Valsalva manouver

Red Flags

• Severe and unremitting pain• Incontinence, saddle anesthesia• Severe or rapidly progressing

neurologic deficit

Age

• More than 50 years old or younger than 18

• Older than 50– Tumor– Abdominal aortic aneurysm– Infection

Age

• Older than 65– Hypertrophic degenerative spinal stenosis

• Under 18– Congenital defect– Tumor– Infection– Spondylolysis– Spondylolisthesis

Duration of Pain

• Approximately 80% of patients with acute low back pain will be symptom-free within six weeks

• Pain lasting longer: tumor, infection, or a rheumatologic etiology

Location and Radiation of the Pain

• Muscular or ligamentous strain or disk disease without nerve involvement– Primarily in the back with radiation into the

buttocks or thighs

• Radiating below the knee, especially calf and foot– Nerve root inflammation below L3 level

• Approximately 95% of all herniated disks occur at the level of either L4-L5 or L5-S1

Location and Radiation of the Pain

History of Trauma

• Major or minor trauma– Elderly or chronic steroid user: Fracture!

• More likely to have osteoporosis

• Fall from a standing or a seated position

Systemic Complaints

• Constitutional symptoms– Fever, night sweats, malaise, or

unintended weight loss– Infection or malignancy

• More worrisome for infection if additional risk factors– Recent bacterial infection– Immunocompromised status

Systemic Complaints

• Injection drug user: assumed to be osteomyelitis or epidural abscess until these conditions are ruled out by diagnostic studies

• Recent invasive procedures, such as colonoscopy

Atypical Pain

• Typical pain: dull, achy pain that is exacerbated with movement and improves with rest

• Tumor and infection– Worse at night– Often awakens patient from sleep– Not relieved with rest– Unrelenting despite appropriate analgesic

treatment

Atypical Pain

• Worsened with prolonged sitting, coughing, and the Valsalva maneuver: Disk Herniation

Associated Neurological Symptoms

• Epidural compression syndrome (spinal cord compression, cauda equina syndrome, or conus medullaris syndrome)– Saddle anesthesia– Bowel or bladder incontinence– Erectile dysfunction– Severe and progressive neurologic deficit

Associated Neurological Symptoms

• Residual bladder volumes– Assist in the evaluation of bladder

incontinence– Large post-void residual volumes:

significant neurologic compromise. Evaluate for epidural compression syndrome

Associated Neurological Symptoms

• Complaints of worsening paresthesias, weakness, gait disturbances– Single nerve root pathology: compression

by a herniated disk– Multiple or bilateral nerve root complaints:

compression from a mass

History of Cancer

• Risk of metastatic spread to the spine

• Most likely to metastasize to the spine:– Breast, lung, thyroid, kidney, prostate

cancer

• Primary tumors originating in the spine:– osteosarcoma, lymphoma, multiple

myeloma, neurofibromas

Physical Examination is Vital!

Physical Examination

• Vital signs– Fever: red flag for infection

• 27% of patients with tuberculous osteomyelitis• 50% of patients with pyogenic osteomyelitis• 87% of patients with spinal epidural abscess• Absence of fever does not rule out spinal

infection

Physical Examination

• General appearance– Benign low back pain: patients prefer to

remain still– Writhing in pain or in extreme pain

• Spinal infection• Abdominal aortic aneurysm• Nephrolithiasis

Physical Examination

• Expose back and palpate– History of trauma: focus on midline spinous

processes for tenderness– Muscular spasm or edema

Physical Examination

• Lower extremity strength and sensation– Focus on muscle groups and dermatomes

innervated by specific spinal nerve roots– Patellar and Achilles reflexes: symmetry– Babinski's test: upper motor nerve

syndrome– All deficits or abnormalities should be

compared with the nerve root involved

Straight Leg Raising• Evaluate for disk herniation• Patient placed in the supine position. Leg

elevated by clinician up to 70 degrees• Positive test: radicular pain below the knee

along the path of a nerve root in the 30- to 70- degree range of elevation

• Further verified by lowering the leg 10 degrees from the point of radicular pain and dorsiflexing the foot

Straight Leg Raising

Straight Leg Raising

• Reproduction of back pain or pain in the hamstring is not a positive test!

• 80% sensitive for disk herniation

• Positive crossed straight leg raise: radicular pain down the affected leg when the asymptomatic leg is raised– Highly specific but not sensitive

Rectal Examination

• Integral part of examination of patients with back pain

• Perianal sensation, rectal tone, and rectal and prostatic masses– Abnormal tone or sensation: bulbocavernous

reflex testing and anal wink

• Poor rectal tone in association with back pain and saddle anesthesia: epidural compression syndrome

Diagnostic Testing

Laboratory Tests

• Infection or tumor: – CBC: elevated WBC count consistent with

infection– ESR: elevated in infection and rheumatologic

disease. Also marker of an undiscovered malignancy

– CRP: same as the ESR– UA: UTI in patients who have evidence of spinal

infection. Urinary system common primary source for such infections

Radiography

• Plain radiographs: simply not necessary in the absence of red flags

• Concern for fracture, infection, rheumatologic disease, or metastatic disease– Anteroposterior and lateral films

• Magnetic resonance imagery (MRI) or computed tomography (CT) if films negative and concern remains

Radiography

• MRI– Gold standard for compressive lesion of

the spinal cord or cauda equina, spinal infection, or disk herniation.

– May be delayed for four to six weeks if disk herniation is the only concern

Radiography

• CT– Study of choice for bony structure

• Spinal trauma: spinal column stability and integrity of spinal canal

• Vertebral osteomyelitis

– CT-myelogram in absence of MRI: epidural compressive lesions

Treatment of Benign Acute Low Back Pain

Activity• No benefit of prolonged bed rest 1

• Recently shown that patients who resumed their normal activities to whatever extent they could tolerate recovered faster than those who stayed in bed for two days

• Active exercise: not beneficial during acute stage

• After recovery, exercise helps prevent future episodes

1. How many days of bed rest for acute low back pain?A randomized clinical trial. N Engl J Med 1986; 315:1064-70

Analgesia

• Mainstays of pharmacologic therapy: acetaminophen, NSAIDs, and opiate analgesics

• Acetaminophen: analgesic with proven efficacy comparable to NSAIDs– Inexpensive– Innocuous side-effect profile

Analgesia• NSAIDs: equally efficacious in the

management of acute pain– Best to choose lowest effective dose based on

side effects and cost

• Opiate analgesics: moderate to severe pain– Combinations of acetaminophen and codeine

phosphate, hydrocodone, or oxycodone

• Other medications– muscle relaxants, such as diazepam,

methocarbamol, and cyclobenzaprine

Sciatica and Back Pain

Sciatica

• Sciatica: pain radiating along a nerve root path to the foot– Afflicts 2% to 3% of patients with low back

pain

• Compression of a nerve root by a herniated nucleus pulposus

• Associated weakness, paresthesias, and numbness along a nerve root

Sciatica

Sciatica• More than 95% of disk herniations occur at

the L4-L5 or L5-S1 levels, corresponding to L5 or S1 radiculopathies

• Other causes of nerve root irritation:– Space-occupying lesions (including central canal

or foraminal stenosis, usually found in patients over age 50)

– Tumor– Hematoma– Infection

Sciatica

Sciatica• Outcome generally positive:

– 50% recovering in six weeks– 5% to 10% ultimately require surgery

• Management similar to uncomplicated low back pain– Limited bed rest– Activity as tolerated– Analgesics– Steroids: epidural steroid injection produces mild

to moderate reduction in pain

Sciatica

• Radiographs not required– Only to rule out bony pathology– MRI: needed emergently only if patient has

a progressing neurologic deficit

Epidural Compression Syndrome

Epidural Compression Syndrome

• Encompasses:– Spinal cord compression– Cauda equina syndrome– Conus medullaris syndrome

• Grouped together because:– Similar presentation except for the level of

the neurologic deficit– Similar evaluation and management until

actual diagnosis is known

Epidural Compression Syndrome

• Medical Emergency!

• Difficult to evaluate patients with early signs and symptoms– Broad initial differential diagnosis– Determine whether symptoms are bilateral– Evaluate combination of motor, sensory,

and autonomic dysfunction

Epidural Compression Syndrome

• Signs and symptoms:– Minimal low back complaints– Constipation or incontinence of the bowel– Urinary retention or incontinence– Saddle anesthesia– Decreased rectal tone

Epidural Compression Syndrome

• Possible etiologies– Large central disk herniation– Spinal canal hematoma– Spinal canal abscess– Primary or metastatic tumor– Traumatic compression

Epidural Compression Syndrome

• Emergent treatment with spinal cord injury assumption:– Dexamethasone 10 to 100 mg IV

administered immediately

• Emergent MRI– Cervical, thoracic, and lumbosacral spine if

concern about possible metastatic compression or infection

Epidural Compression Syndrome

• Outcomes dependent on presenting neurologic deficits– Paraplegic on presentation - unlikely to walk again– Too weak to walk without assistance, but not

paraplegic - 50% chance of walking again– Ambulatory at presentation - remained so– Catheterized for a denervated bladder – most will

not recover bladder function

Vertebral Osteomyelitis

Vertebral Osteomyelitis

• Often missed on routine examination• History very helpful in making diagnosis

– 90% have back pain as primary symptom– Severe pain, commonly nocturnal and unremitting– Only 52% febrile at presentation– Only 10% appear septic or toxic– Injection drug use: assumed to be osteomyelitis or

epidural abscess until proven otherwise– Recent UTI, pneumonia, GI or GU procedure

Vertebral Osteomyelitis

• Transplant patients and other immunocompromised patients: increased risk for septicemia and osteomyelitis

• Organisms:– Staphylococcus aureus most common– Escherichia coli, Proteus, and Pseudomonas

• Hematogenous spread with deposit in the vertebral matrix around the sluggish venous plexuses

Vertebral Osteomyelitis• Evaluation

– WBC count may be elevated– ESR almost always elevated – Urinalysis – Blood cultures positive in more than 40% – Plain radiographs: may be normal

• Bony destruction, moth-eaten end plates, and narrowing of disk spaces

– MRI: gold-standard• Brightening of the marrow on T2, brightening of the disk

on T2, and darkening of the marrow on T1

Vertebral Osteomyelitis

Vertebral Osteomyelitis• Cornerstone of treatment: IV antibiotics

– Six to eight weeks IV antistaphylococcal– Followed by oral antibiotics for another four to

eight weeks– Analgesics and bed rest– Immobilization with an orthosis– Surgery reserved for:

• Significant abscesses• Spinal cord compression• Significant bony destruction• Unresponsive to standard medical treatment

Back Pain in the Cancer Patient

The Cancer Patient

• Difficult to evaluate:– Spinal metastases– Devastating consequences if significant

lesion is missed

• Separate patients into three groups based on symptoms

The Cancer Patient

• First group– Signs and symptoms of progressive

epidural compression– True medical emergency– High-dose steroids and emergent MRI

The Cancer Patient

• Second group– Mild, stable symptoms– Isolated nerve root involvement– Do not require high-dose steroids or

emergent MRI

The Cancer Patient

• Third group– Majority of patients– Isolated pain with no neurologic deficits– Plain radiographs: MRI if metastases detected– Followed closely for two to three weeks– Remember:

• 50% bone destruction must occur before radiographs can detect a lytic lesion

• 60% of patients with metastatic disease will have normal radiographs

Summary• History: Keep red flags in mind• Physical Exam: red flags again• SLR and Sciatica• Treatment for benign low back pain is

analgesics• Epidural compression syndrome is a

medical emergency• Appropriate imaging. Plain films usually

not needed

References

• www.emedicine.com• www.mdchoice.com• www.webmd.com• Emergency Medicine – Judith E.

Tintinalli. 6th Edition• Rosen’s Emergency Medicine – 5th

Edition

Thank You!