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

CAUDA EQUINA SYNDROME

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