headaches, dizziness, back pain, oh my! - · pdf file©2015 mfmer | slide-1 headaches,...

Joint Session with ACOFP and Mayo Clinic

Headaches, Dizziness, and Back Pain - Oh My!

William Cheshire, M.D.

9/25/2015

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©2015 MFMER | slide-1

Headaches, Dizziness, Back Pain,

Oh My!

William P. Cheshire, Jr., M.D.

Professor of NeurologyMayo Clinic in Florida

AOA/ACOFP OMED 2015

Osteopathic Medical Conference

Orlando, Florida

October 19, 2015


Disclosures

• No relevant financial conflicts of interest

• I will not discuss off-label drug use

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The Scenario

• It’s Monday. You have a full clinic schedule.

• At the end of the day today you are scheduled to catch a plane

• to attend an obligatory educational program for your maintenance-of-certification.

• Patient office visits in your practice are compressed to 15 minutes.

• No problem, your policy is to limit your evaluation to just one chief complaint.


The Challenge

• You enter the room to see your last scheduled appointment for the day:

• Dorothy, a 45-year-old meteorologist from Kansas, presents with the chief complaint of

1. Headaches

2. Dizziness

3. Back pain

• How should you proceed to provide a focused, responsible evaluation when you have only 15 minutes?

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Options

1. Panic or do nothing• Not a good option. You are a professional.

2. Do everything• Spend an hour, maybe two, even if that means

canceling all your other appointments and obligations.

• Unrealistic. You are human.

• You can’t do that for all patients. If you were to try, that would be a sure recipe for burnout, divorce, and failure in other areas.


Options

3. Negotiate• With the patient

• Which symptom is most important to you?

• Can we schedule another visit to address the other concerns?

• Would you like me to refer you to a specialist?

Dorothy’s response: “All are all important, all are urgent.

I can’t come back another day because I am needed to

help with a whirlwind of problems back home in Kansas.

I need you to evaluate me now, in toto. You are the only

doctor I trust. Surely you won’t let me down!

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Options

4. Negotiate• With yourself

• Goals• Identify, not miss

• Serious pathology if present

• Life-threatening

• Potentially disabling

• Treatable disease

• Patient’s fears

• Avoid spending too much time on nonessentials

Achievable with

knowledge and

experience


Prevalence in the general population

• Headache 15%• 20% in women, 9% in men

• Dizziness 30%

• Back pain 90% during lifetime• Annual incidence of 5%

• Burch RC, Loder S, Loder E, Smitherman TA. The prevalence and burden of migraine and severe headache in the

United States: updated statistics from government health surveillance studies. Headache 2015; 55(1): 21-34.

• Rubin DI, Cheshire WP. Evaluation of dizziness in the neurology office. Semin Neurol 2011; 31(1)L: 29-41.

• Della-Giustina D. Evaluation and treatment of acute back pain in the emergency department. Emerg Med Clin

North Am 2015; 33(2): 311-326.

These are common complaints

Most often benign – but not always!

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Headache

• What not to miss in the history• A “first or worst” headache

• Recent head trauma

• New onset headache after age 50

• New onset headache in an immunosuppressed patient

• New onset seizures, cognitive impairment, or personality changes

• History of cancer

• Loss of vision

• Postural or exertional headache

• Hypercoagulable state

Thunderclap headache:

abrupt onset reaching

maximum intensity in

less than 1 minute.

Clearly stands out from

previous headaches.

Not always intense in

severity.

Neuroimaging is

needed if any of

these is present


Headache

• What not to miss on your exam• Temperature – fever can signal meningitis

• Blood pressure – hypertensive encephalopathy

• Neck stiffness – meningitis

• Papilledema – increased intracranial pressure

• Mentation – intracranial mass or infection

• Eye movements – orbital or cavernous sinus lesion

• Babinski – intracranial mass lesion or stroke

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Headache

• Further Acute Investigations

• Sedimentation rate

• >50 years, new headache, visual changes

• Brain imaging

• CT

• MRI

• MRA or CTA

• Contrast if concerned about infection, metastasis, arteriovenous malformation or low CSF pressure

• Lumbar puncture

• Acute thunderclap headache

• Fever, meningismus

• If you think about it, you should probably do it

• Head CT can be normal in 10-15% of patients with subarachnoid hemorrhage, particularly if delayed

• Head CT is normal in acute bacterial meningitis.

• If meningitis is suspected, don’t wait to give IV antibiotics. Giving first dose prior to CSF cultures does not invalidate them.


PapilledemaPRES

(Posterior Reversible Encephalopathy Syndrome) Cerebellar hemorrhage

Subarachnoid hemorrhage Basal ganglia hemorrhage Tumor

MRI MRI

MRICTCT Angiogram:

aneurysm

Funduscopic exam

Not to Miss

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Dizziness

• What not to miss in the history

• What do you mean by “dizzy”?• Vertigo (an illusion of movement)

• Lightheadedness (feeling faint)

• Imbalance (unsteadness)

• Provoking factors• Head movement (vestibular)

• Standing up (orthostatic disorders)

• Walking (gait disorders)


Dizziness

• What not to miss on your exam• Blood pressure, supine and standing

• Orthostatic hypotension is defined as of >20 mmHg systolic or >10 mmHg diastolic

• Eye movements

• Nystagmus

• Restriction of movement

• Hearing

• Gait

• Ability to maintain balance

• (Cerebellar testing, reflexes, sensation)

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MRI brain with contrast

Bilateral vestibular

schwannomas in

neurofibromatosis type 2

Right vestibular schwannoma


• Age <18 years – congenital bony abnormality

• Age >50 years – fracture, abdominal aortic aneurysm, cancer

• Major trauma – or minor trauma in the elderly

• Cancer history – spinal metastasis

• Fever, chills, night sweats – infection, e.g., diskitis, epidural abscess

• Weight loss – infection or malignancy

• Recent genitourinary or gastrointestinal procedure – infection

• Immunocompromised status – infection

• Pain worsened by Valsalva maneuvers – herniated disk

• Pain at night or unrelenting – infection or malignancy

• Incontinence – cauda equina lesion

• Pain radiating below the knee – herniated disk

• Exam:

• Lower extremity weakness, especially if recent or rapidly progressive

• Saddle (perineal) anesthesia

Back Pain – Red Flags

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Back Pain

• What not to miss on your exam• Temperature

• Signs of external trauma, e.g., contusion

• Spinal tenderness

• Abdominal exam assessing for tenderness, abdominal bruit or abnormal pulsatility

• Straight leg raising

• Patient is supine

• Raise each leg 70º

• Positive if this produces radicular (not back) pain

• Focused neurologic exam


Back Pain

• What not to miss on your exam• Focused neurologic exam

• Tendon reflexes

• Knee jerk L3-4

• Ankle jerk S1

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Spinal Root Nerve Muscle Test (against resistance)

L2,3,4 Femoral Iliopsoas Hip flexion

L2,3,4 Obturator Thigh adduction Press knees together

L4,5, S1 Superior gluteal Thigh abduction Pull knees apart

L2,3,4 Femoral Quadriceps Knee extension

L4,5, S1 Sciatic Hamstrings Knee flexion

L4,5 Peroneal Tibialis anterior Dorsiflex foot, walk on heels

L5 Peroneal Extensor hallucis

longus

Great toe extension

L5, S1 Peroneal Peronei Foot external rotation

L5, S1 Tibial Posterior tibial Foot internal rotation

S1,2 Tibial Gastrocnemius Foot flexion, walk on toes

Lower Extremity Strength Exam


Spinal Root Nerve Muscle Test (against resistance)

L2,3,4 Femoral Iliopsoas Hip flexion

L2,3,4 Obturator Thigh adduction Press knees together

L4,5, S1 Superior gluteal Thigh abduction Pull knees apart

L2,3,4 Femoral Quadriceps Knee extension

L4,5, S1 Sciatic Hamstrings Knee flexion

L4,5 Peroneal Tibialis anterior Dorsiflex foot, walk on heels

L5 Peroneal Extensor hallucis

longus

Great toe extension

L5, S1 Peroneal Peronei Foot external rotation

L5, S1 Tibial Posterior tibial Foot internal rotation

S1,2 Tibial Gastrocnemius Foot flexion, walk on toes

Lower Extremity Strength Exam

>95% of herniated disks occur at the L4-5 or L5-S1 levels

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Back Pain

• Tests• If infection is suspected

• Sedimentation rate

• Urinalysis

• Blood cultures

• Plain x-rays if:

• New pain

• Suspicion of fracture, cancer, infection

• MRI (usually preferable to CT) if:

• Suspicion for cancer or infection

• Lower extremity motor deficit

• Incontinence or saddle anesthesia


Epidural hematomaMRSA epidural

abscess and T5

compression fracture

Meningioma

Examples of Spinal MRI Abnormalities

http://intranet.mayo.edu/charlie/neurology-education-rst/files/2013/12/case186b.jpg

http://intranet.mayo.edu/charlie/neurology-education-rst/files/2013/12/case186b.jpg

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Returning to our case: Dorothy

• Headache

• Gradual onset over 2 weeks

• Dull, holocephalic and mainly bifrontal

• Worse upright (8/10), rapidly relieved by lying down (1/10)

• Dizziness

• Woozy or lightheaded feeling, sometimes vertigo too

• Muffled or distorted hearing

• Nausea

• Diplopia when looking to the left

• Back Pain

• Not lumbar; rather lower cervical and interscapular, dull, mild

• Slight tingling radiating down right arm


Dorothy

• Physical Examination

• NORMAL

Would you arrange for an imaging study?

Why or why not?

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Occam’s razor

• William of Ockham (c. 1287-1347)

• Among competing hypotheses that predict equally well, the one with the fewest assumptions should be selected.


• Postural headache resulting from cerebrospinal fluid volume depletion

• Causes include

• Spontaneous CSF leaks

• Nerve root sleeve trauma (automobile or sports injuries)

• Iatrogenic, following dural puncture

• Connective tissue matrix weakness, e.g.,

• Marfan syndrome

• Joint hypermobility

• Meningeal diverticulae

• MRI

• Meningeal engorgement and enhancement

• Descent of the cerebellar tonsils (sagging)

• CT myelography (study of choice)

• May identify a CSF leak

• (Radionuclide cisternogram)

• Treatment

• Bedrest awaiting spontaneous resolution

• Overhydration

• Epidural blood patch

• Refractory cases

• Epidural fibrin glue

• Surgical repair of leak

Spontaneous Intracranial Hypotension

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For further reading

• Dodick DW (editor). Headache. Continuum Lifelong Learning in Neurology 2015; 21(4), entire issue.

• Cheshire WP. Autonomic Disorders and Their Management. In: L Goldman, AI Schafer (editors), Goldman-Cecil Medicine, 25th Edition. Philadelphia: Elsevier Saunders, 2016, pp. 2517-2522.

• Rubin DI, Cheshire WP. Evaluation of dizziness in the neurology office. Seminars in Neurology 2011; 31(1)L: 29-41.

• Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Autonomic Neuroscience 2011; 161: 46-48.

• Della-Giustina D. Evaluation and treatment of acute back pain in the emergency department. Emerg Med Clin North Am 2015; 33(2): 311-326.

headaches, dizziness, back pain, oh my! - · pdf file©2015 mfmer | slide-1 headaches,...

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