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Medical BitesBack Pain

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Back Pain

Lecture to go with Medical Bites

Back PainRed Flags for diagnoses not to miss Acute on chronic pain associated with increasing

weakness (CES) Weakness or sensory symptoms associated with

systemic symptoms, such as fever or nausea, implies an infective cause

Neurological symptoms and signs of any kind without a clear explanation

Warfarin use and back pain is retroperitoneal haemorrhage until proven otherwise

Back PainRed Flags for diagnoses not to miss A past medical history of cancer associated with

new back pain equals malignant metastases until proven otherwise

New atrial fibrillation associated with new back pain, especially in as yet anticoagulated patients, equals ischaemia of the spinal cord

Back PainObjectives

To be able to assess, diagnose and treat serious and common presentations of back pain

To be aware of the risks and red flags associated with back pain

Back PainDefinitions

Pain described by the patient or clinician as arising from the back.

Back PainRisks

Rupture Abdominal Aortic Aneurysm (AAA) Renal colic Pneumonia Retroperitoneal Haemorrhage Remember the Drug seeker, but don’t make it

life’s ambition Spine, infection, malignancy and fracture Cauda equina( the major back emergency)

Back PainRecognition of illness

Always need to assess for Potential airway compromise Potential respiratory failure Potential circulatory failure Potential neurological failure Vitally important to identify when any patient

approaches the end of their ability to compensate for illness or injury

Just because a clinical variable is normal does not mean that it still will be in 5 minutes time

Back PainRecognition of illness Clinical signs of potential ABCDE system failure

are similar whatever the underlying process These signs reflect failing respiratory,

cardiovascular and neurological systems We therefore always need to assess ABCDE to

identify failure in one system, AND the effect of failure on other systems

If we treat immediately, we prevent further harm

Back PainImmediate actions

Global overview of patient Speak to patient Formally examine ABCDE Treat problems in systems - find an airway

problem, treat it immediately… Resuscitate - aim to reverse immediate

problems and halt deterioration - NOT to aim for normal physiological values

Back Pain History – important points

Traumatic? Onset and course, is it…

Persistent (malignancy, infection) Acute (musculoskeletal) Acute on chronic (pathological) Chronic (degenerative)

Urinary / sexual dysfunction Neurological symptoms (cauda equina, nerve

route compression)

Back Pain History – important points

Unexplained fevers (infection) Unexplained weight loss (malignancy) Past back injuries or problems (musculoskeletal) Past medical problems - malignancy,

immunocompetency (metastases) Social circumstances (disposition)

Back PainThe pain

Onset rapid with musculoskeletal slow with infection and malignancy Associations - immediate and delayed

Exacerbation musculoskeletal improves with rest or lying

still renal colic tends to make you move around relief

Back PainThe pain

Referral patterns dermatomal patterns remember there are referral patterns with

musculoskeletal pathology which is non-dermatomal

Current analgesia taken, frequency, regularity and doses

Back painExamination

Global overview Behaviour Position e.g. lying straight and immobile with

musculoskeletal pain Moving around e.g. with renal colic Leaking or ruptured AAA can appear in many

guises depending on the extent of the leak but may look very unwell

Neurological examination lower limbs Straight leg raise (SLR) - positive test is pain to

the foot on extending the straight leg, implies nerve root lesion

Muscle for Spasm, Bony Tenderness

Saddle Anaesthesia, Sphincter competence ( Cauda Equina)

Abdominal Exam ( masses pulsatile, expanding, flank can all be AAA.)

Back PainInvestigations Often none required, apart from where there is

indication from history or examination that there is serious / systemic illness associated with pain

Bedside Random blood glucose for diabetes (infection

neuropathy risk) ECG for atrial fibrillation (embolic risk leading to

spinal ischaemia)

Back PainInvestigationsBedside Urinalysis for blood (serious loin pain without

haematuria may still be renal colic but AAA must be considered until excluded by ultrasound or CT

Laboratory FBC - Hb (anaemia from leaking AAA,

malignancy), WCC (infection) EUC - renal function, metabolic disturbances Blood cultures - if febrile

Back PainInvestigationsImaging A number of ED physicians / surgeons can do

ultrasound scans to investigate for AAA Attempt to organise this investigation rapidly

when there is any suspicion of a leaking aneurysm (i.e. any older person with abdominal pain when another convincing diagnosis is not immediately apparent)

Back PainInvestigationsImaging Lumbar spine or other X-rays may be helpful,

but where there is acute atraumatic or low impact traumatic musculoskeletal pain presenting for the first time in the ambulatory patient, they very rarely are

In fact there is little correlation between X-ray findings and pain scores

Back PainInvestigationsImaging CT scans are often performed for back pain,

but when they are not specifically targeted at investigating serious pathology such as malignancy / metastases or fractures (where mechanism or clinical picture or plain films suggests fracture) they very rarely change management

Back PainInvestigationsImaging Minor disc lesions and degenerative changes

which do not necessarily correlate with symptoms are often disturbing and misinterpreted by clinicians and patients

Consider…. If you are doing a CT scan of the back you

are giving a large radiation load

Back PainInvestigationsImaging

Particularly in young and women patients you must have a clear set of differential diagnoses and treatment plans in mind, depending on your result

If you cannot do this then refer on for more senior consultation

Back PainInvestigations

Imaging MRI may be performed as an emergency

investigation where there is suspicion of cauda equina syndrome (the major diagnosis not to miss), in order to diagnose spinal cord compression

This is done urgently and often requires a number of phone calls or transport out of regular hours to another facility

MRI for other indications is not an emergency Investigation

Back PainDiagnoses not to miss

Cauda equina syndrome (CES) - a neurological emergency

Fractures of any kind, particularly unstable ones

Infections of the spine, often at the extremes of age

Inflammatory conditions of the spinal cord Nerve root compressions Blood supply compromise e.g. secondary to

AF, emboli

Back PainRed Flags for diagnoses not to miss Acute on chronic pain associated with increasing

weakness (CES) Weakness or sensory symptoms associated with

systemic symptoms, such as fever or nausea, implies an infective cause

Neurological symptoms and signs of any kind without a clear explanation

Warfarin use and back pain is retroperitoneal haemorrhage until proven otherwise

Back PainRed Flags for diagnoses not to miss A past medical history of cancer associated with

new back pain equals malignant metastases until proven otherwise

New atrial fibrillation associated with new back pain, especially in as yet anticoagulated patients, equals ischaemia of the spinal cord

Back Pain Specifics Cauda equina syndrome (CES) Infection Nerve root compression Inflammatory and ischaemic Musculoskeletal

Fractures Muscular pain

Back Pain SpecificsCauda Equina syndrome (CES) Low back pain Unilateral or usually bilateral sciatica Saddle sensory disturbances Bladder and bowel dysfunction Variable lower extremity motor and sensory loss

Back Pain CES - pathophysiology Compression of susceptible cauda equina nerve

roots May be caused by…

Trauma Lumbar disc disease Abscess Spinal anesthesia

Back Pain CES - pathophysiology Compression of susceptible cauda equina nerve

roots May be caused by…

Tumour, either metastatic or CNS primary Late-stage ankylosing spondylitis Idiopathic Inferior vena cava thrombosis Lymphoma or sarcoidosis

Back Pain CES - history Low back pain Acute or chronic radiating pain Unilateral or bilateral lower extremity motor

and /or sensory abnormality Bowel and / or bladder dysfunction; symptoms

may be described within a spectrum from hesitancy to incontinence, which is overflow from an atonic bladder

Saddle (perineal) anaesthesia

Back Pain CES - examination Local lumbar tenderness to palpation or

percussion Reduced reflexes (not increased reflexes which

implies an upper motor neurone lesion in the spinal cord)

Sensory abnormalities over the perineal area or lower extremities Light touch in the perineal area should be

tested Muscle weakness may be present in muscles

supplied by affected roots

Back Pain CES - examination Muscle wasting may occur if CES is chronic Poor anal sphincter tone is characteristic of CES Babinski sign or other signs of upper motor

neuron involvement, suggests a diagnosis other than CES, such as an intrinsic cord lesion or external compression

Anaesthetic areas may show skin breakdown A large residual post-void urine as measured by

catheterisation

Back Pain CES - investigationBedside Urinalysis for infectionLaboratory FBC

WCC - investigating for infection Hb - investigating for malignancy

Imaging Key investigations are imaging

Back Pain CES - investigationImaging Plain radiography usually not helpful, however

may be used to look for destructive lesions, disc-space narrowing, or spondylolysis (degeneration of an articulating part of a vertebra)

CT with / without contrast - lumbar myelogram followed by CT

MRI - currently considered a requirement in suspected CES, but improved CT scanners may disprove this

Back Pain CES - treatment If suspect CES consult neurosurgical early for

directed investigations and ongoing management

Early steroids may be used Surgical decompression may be appropriate,

depending on aetiology Depending on local institutional practice surgery

may be performed early, intermediate or late Specific treatments such as antibiotics depend

on suspected causes

Back Pain Infection Pyogenic vertebral osteomyelitis is the most

commonly encountered form of vertebral infection

Aetiology may be from direct open spinal trauma infections in adjacent structures hematogenous spread of bacteria can occur postoperatively

Left untreated, it can lead to permanent neurologic deficits, significant spinal deformity, or death

Back Pain Infection – risk factors Advanced age Intravenous drug use Congenital immunosuppression Long-term systemic administration of steroids Diabetes mellitus Organ transplantation Malnutrition Cancer

Back Pain Infection - history Back pain which is increasing, and lasting for

weeks to months Fever is present in around 50% of patients

Back Pain Infection - examination Local tenderness, which may be initially mild Neurologic signs are usually late and occur due

to bony destruction Decreased range of motion Radicular (nerve root) signs and paralysis

suggest epidural abscess

Back Pain Infection - examination Sensory examination includes

sensory level heat / cold pain reflexes rectal tone perianal sensation

Back Pain Infection - investigationBedside Urinalysis - infection, diabetes, bloodLaboratory VBG - metabolic status FBC - WCC as sign of infection Other inflammatory markers are often performed

(ESR, CRP) but do not rule in or rule out infection, and are often a waste of time

Blood cultures may be of benefit Clinical suspicion mandates further testing with

imaging

Back Pain Infection - investigationImaging Plain radiography will show late destructive

lesions CT with and without contrast MRI if available and most likely after CT Technetium uptake scans for activity of

osteomyelitis

Back Pain Infection - treatment Assessment using ABCDE, as infective back

pain may represent an underlying systemic sepsis or may lead to this

Keep tuberculosis in mind, particularly in at-risk groups

Initially broad spectrum antibiotics are used, however consult early and widely, including microbiology

Back Pain Infection - treatment Adequate analgesia – often requiring IV opiates The premorbid state which allows spinal

infection implies the patient is at risk of numerous pathologies, therefore a full medical workup is required but is likely to occur over time as an in-patient

Back Pain Nerve root compression This back pain diagnosis is one of the more

clear cut, given that the history refers to both motor and sensory issues in a nerve root distribution, with concurrent reflex abnormalities

Key point - signs must fit the nerve root distribution, and there must not be signs or symptoms suggestive of other red flag pathologies, such as infection or cauda equina syndrome

The key to nerve root distributions is dermatomal pattern, and which roots are involved in various muscle groups (myotomes) and reflexes

Back Pain Nerve root compression - history Pain as initial complaint, then varying degrees of

weakness as a later symptom May be history of trauma, and often of chronic

back pain Specifically question to elicit symptoms of

infection or malignancy, including fevers, weight loss and general malaise

Pain medication history is important, to gauge both pain severity and potential for dependence after prolonged use

Back Pain Nerve root compression - examination Lower limb for obvious asymmetry of colour and

skin texture, to detect other system involvement such as Circulation

Full neurological examination of lower limb *(see practical skills)

Straight leg raise (SLR), is positive when the leg is elevated with the patient supine and pain radiates to the foot; this implies a nerve root lesion

Back Pain Nerve root compression - examination Sensory landmarks

C6 at the thumb T4 at the nipple T10 at the umbilicus L5 at the top of the foot S1 over the sole of the foot S2-S4 at the perineum

(see dermatome chart)

Back Pain Nerve root compression

Back Pain Nerve root compression - investigationBedside Urinalysis - infection, diabetes, bloodLaboratory As indicated by history and examination,

however none may be indicatedImaging Plain X-rays are usually of no use but be guided

by the patient history

Back Pain Nerve root compression - investigationImaging CT scan may be of use but it will confirm nerve

root compressive elements MRI may be required Importantly, often none of the above are urgent if

no red flags are present

Back Pain Nerve root compression - management Early, effective analgesia is the key to treating

any back pain IV opiates if needed ‘Triple analgesia’

Paracetamol 1g 6 hourly PO Ibuprofen 400mg 6-8 hourly PO Oxycodone 5mg 6 hourly PO

Back Pain Nerve root compression - management Together with analgesia and reassurance, early

referral for assessment and specialist management of nerve root symptoms is the mainstay of treatment

For significant symptoms such as debilitating weakness, or unrelieved pain, admission may be very rarely required

Back Pain Inflammatory and ischaemic These are very important diagnoses and often

very difficult to appreciate early the key is to respond to positive findings and

indicators in your history and examination by appropriate investigations, and thereafter by referral

If you have a positive finding do not ignore it because it does not fit your diagnosis.

If it doesn’t fit it may be spurious but it may also be part of a complex presentation; always ask senior ED and refer if possible

Back PainThe commonest diagnosis Musculoskeletal mechanical back pain Logically this is divided into…

Fractures Muscular pain

Back Pain Fractures The diagnosis of fractures starts with

suspicion… when there is a mechanism which could

transmit significant load to the back, including compressive forces such as a heavy object hitting the top of the head and transmitting energy down the spine

Back Pain Fractures - examination Primary survey, ABCDE approach and

immediate resuscitation in systems, including oxygen, IV analgesia and fluids via x2 large bore cannulae (see serious trauma lecture)

Call for help early - senior ED Thorough top to toe examination (secondary

survey) Full neurological examination This will then direct you, given the background

level of suspicion to appropriate imaging, remembering Nexus / Canadian C-spine rules

Back Pain Fractures - examinationNexus rulesIf the patient is alert, and there is… No neck pain No posterior midline cervical spine tenderness

present No evidence of intoxication present A normal level of alertness No focal neurologic deficit present No painful distracting injuryYou do not have to image this patient

Back Pain Fractures - examinationCanadian C-spine rule Patient alert (GCS 15) Not intoxicated No distracting injury (e.g. long bone fracture, large

laceration) The patient is not high risk (age >65 years or dangerous

mechanism or paraesthesia in extremities) A low risk factor that allows safe assessment of range of

motion exists. This includes simple rear end motor vehicle collision, seated position in the ED, ambulation at any time post-trauma, delayed onset of neck pain, and the absence of midline cervical spine tenderness

The patient is able to actively rotate their neck 45 degrees left and right

Back Pain Fractures - management Any patient in which a spinal fracture is

suspected must be kept immobilised and other suspicious areas imaged, i.e. when there is one spinal fracture there is a 10% likelihood of another being present

Immobilisation means a C-collar needs to be applied and remain in place, and the patient log rolled when transport or movement required (see practical skills)

Back Pain Fractures - management Analgesia, using morphine IV titrated to pain Antiemetics, traditionally metclopramide 10mg,

and more recently ondansetron 4 mg IV Steroids may be requested by neurosurgeons

managing the patient

Back Pain Muscular – introduction A number of both senior and junior doctors

dislike seeing back pain patients; this is because of the perceived difficulties in their management

As with all our difficult ED patients, when a system is applied it assists the resolution of the patient’s problems, and the dilemma of the clinical staff.

The key to adequate treatment of back pain is getting the confidence of the patient early

Back Pain Muscular - history Often there is no history of major or even minor

trauma, but sudden onset after, for example, ‘bending to pick up a pen’

There is usually back-straining activity in the last two weeks, or there is a history of a back-intensive occupation such as bricklayer or mother of young children

Red flags, as mentioned earlier, need to be carefully excluded

Back Pain Muscular - examination ABCDE Full neurological examination including SLR Full examination looking for other systems

pathology as indicated Examination may be normal, but limited due to

pain; if this is the case you have given enough analgesia to relieve resting discomfort

Back Pain Muscular - investigation None

Back Pain Muscular - management Early analgesia, in adequate amounts, is the

mainstay of treatment See triple therapy described earlier Ensure you give a clear explanation that the

medications in triple analgesia therapy are… …metabolised separately, so no risk of

overdose …multiplicative rather than additive, so give

added analgesia …taken regularly rather than PRN, to

ensure adequate ‘levels of pain relief’

Back Pain Muscular - management

Start on full dose triple therapy, and give clear instructions about titrating analgesia down

To get the patients confidence you must get their comfort and then you will get cooperation

If pain is severe, control initially with morphine and then introduce oral medications early if you intend to discharge the patient (you do!)

The principle is the oral medications take over from the morphine and discharge can be facilitated

Back Pain Muscular - management If you incrementally increase / escalate pain

medications because each one does not work individually, the patient will remain longer in the ED, you will lose their confidence and make discharge harder

Therefore - titrate morphine 5 mg + 2.5mg IV…etc until pain relief achieved

Depending on amount required after 2 hours add in oral paracetamol 1g and oxycodone (5mg for milder pain, 10mg for more severe)

When patient has had some food give some ibuprofen 400mg

Back Pain Muscular - management In this way, after 3-4 hours, and even in patients

with severe back pain, you may have someone who is able to be discharged

For less severe pain, commence with either ibuprofen, paracetamol or oxycodone depending on the level, or potentially a combination of two agents rather than three

Ensure, however, that the patient has good analgesia, rather than worry about too much analgesia

Discuss ongoing requirements and the pathophysiology of the pain with the patient

Back Pain Muscular - management Explain that the severity of the pain often does

not reflect the amount of pathology or damage, and that the spasm is a protective mechanism

If discharging the patient, you need to know full social circumstances

Advise that manipulation should not be done acutely and may not help in the long term, but good advice regarding back management from physiotherapists and osteopaths may

Remember a number of patients will attend other clinicians and rather than disregarding this you should advise how best to use them

Back Pain Summary Give analgesia in adequate amounts, titrate in a

timely fashion Keep red flags in mind, and if the history and

examination does not fit then be suspicious Drug seeking is a possibility, but be careful with

this as a diagnosis (e.g. IVDUs get spinal infections). It is better to give an opiate addicted person one episode of medication than to deny a person in pain the analgesia they really need

We need to engender Comfort, Confidence and Cooperation

Back Pain Summary The patient who cannot be discharged due to

pain or social circumstances should get admission; but you will need to negotiate local custom whether it is appropriately medical (more common in elderly), orthopaedic or neurosurgical as the admitting team. (They are all wankers anyway!)

When referring be sure you have adequately trialed analgesia, have a clear clinical picture and can present the patient concisely to the ED senior or other clinician