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Low Back Pain Brad Bunney, MD Department of Emergency Medicine University of Illinois College of Medicine-Chicago Chicago, IL - PowerPoint PPT Presentation


Low Back Pain Brad Bunney, MD Department of Emergency Medicine University of Illinois College of Medicine-Chicago Chicago, IL. Objectives. Discuss the different types of back pain Review anatomical principles Review nontraumatic etiologies for acute back pain with neurological findings

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Low Back Pain Brad Bunney, MD Department of Emergency Medicine University of Illinois College of Medicine-Chicago Chicago, IL

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Low Back PainBrad Bunney, MDDepartment of Emergency MedicineUniversity of Illinois College of Medicine-ChicagoChicago, IL


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Objectives

  • Discuss the different types of back pain

  • Review anatomical principles

  • Review nontraumatic etiologies for acute back pain with neurological findings

  • Treatment options for patients with back pain and neurological findings


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The Case

55 yo male with low back pain. The pain is sharp, right-sided, worse with movement and non-radiating. He has no weakness, numbness or incontinence. No hx of trauma.

Pmhx: HTN, irritable bowel syndrome, cervical disc herniation

Meds: none

Sochx: alcohol use

PE: afebrile, VSS

Back: mild tenderness right paraspinal area, L2-3

Neuro: normal

What do you want to do?


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The Case

He is given valium which makes him better and is sent home. 5 days later he is at a new hospital with the complaint of back pain, says it is the same as before, “I ran out of my Valium”.

PE: Afebrile, VSS

Back: right paraspinal tenderness, worse with movement

Neuro: normal

What do you want to do?


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The Case

He has an abdominal CT scan to R/O renal stone which was normal. He is given a shot of Torodol which makes him feel better and is discharged with Motrin and Valium. He returns 2 days later with worsening pain that radiates to the right foot and left knee. He has numbness to the thighs and groin, and has been incontinent of stool.

PE: Afebrile, VSS

Back: diffuse tenderness to lumbar spine palpation

Neuro: RLE- 3/5 strength, numbness anterior and med thigh, decreased reflex. LLE- 4/5 strength.

What do you want to do?


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Epidemiology

60-90% experience back pain in lifetime

5 million disabled

No definitive diagnoses in 80%

90% get better no matter therapy


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Anatomy

Vertebra – body, neural arch, bony process

Ligaments & muscles = stability

Cervical nerve roots pass above body

All others pass below


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Types of Back Pain

Local

Referred

Radicular


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Types of Back Pain Local

Irritation of bone, muscle, joints

Steady, sharp or dull

Worse with movement


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Types of Back PainReferred

Non-spinal referred to back

- Abdominal aortic aneurysm

Originate in spine but felt elsewhere

- Upper lumbar pain felt in upper thighs

Rarely extends below the knee


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Types of Back PainRadicular

Irritation of the nerve root

Can radiate to the calf and feet

Worse with movement that increases CSF pressure


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Nerve Root DiagnosisL4

Pain = lateral back, antero-lateral thigh, anterior calf

Numbness = anterior thigh

Weakness = quadriceps

Diminished knee jerk

Squat and rise


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Nerve Root DiagnosisL5

Pain = hip, groin, postero-lateral thigh, lateral calf and dorsum of foot

Numbness = lateral calf

Weakness = dorsiflex great toe

Heel walking


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Nerve Root DiagnosisS1

  • Pain = mid-gluteal region, posterior thigh, posterior calf to heel & sole

  • Numbness = posterior calf

  • Weakness = plantar flex great toe

  • Diminished ankle jerk

  • Walk on toes


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Spinal Cord Compression

Malignant epidural spinal cord compression (MESCC)

Disc herniation

Spinal epidural abscess (SEA)

Spinal epidural hematoma (SEH)


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Spinal Cord Compression Factors

Force of compression

Direction of compression

Rate of compression


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MESCC

Hematogenous spread

Bone marrow

Compress cord and vascular supply

Edema, infarction


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MESCC

Prostate

Lung

Breast

Non-Hodgkin’s lymphoma

Multiple myeloma

Renal cell cancer


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MESCC

Initial presentation in 20% of malignancies

Cervical, thoracic & lumbar by proportion of vertebral body volume

Thoracic is most common


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MESCC

95% have back pain

Precedes other symptoms by 1-2 months

Percussion tendencies, thoracic location, worse lying down


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MESCC

75% have weakness by time of diagnosis

Weakness symmetric

Ascending numbness

Autonomic dysfunction, urinary retention


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MESCC

Plain X-ray 10-17% false negative

30-50% of bone must be destroyed for X-ray to be positive

MRI, CT myelography are standards


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MESCC

Corticosteroids first line for edema

Dexamethosone, 20-100 mg load, 4-24 mg 4 times/day

Radiation therapy within 24 hours


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MESCC

Surgery for:

unresponsive to radiation therapy

Acute neurological deteriorations

Chemotherapy – Non-Hodgkin’s lymphoma


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Disc Herniation

L4-5, L5-S1 most common

Cervical and thoracic do occur

Thoracic: abrupt neuro deficits

Narrow canal

Postero-lateral aspect of the disc


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Disc Herniation

Not necessary to have history of strain or injury

Unilateral radicular back pain with nerve root impingement


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Disc Herniation

X-ray only good if inter-vertebral disc is narrow

MRI is gold standard

Electromyelography localizes the specific nerve root


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Disc Herniation

Initial therapy is to decrease pressure on the root

Bed rest up to 4 weeks

Non-steroid anti-inflammatory

Muscle relaxants


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Disc Herniation

Absolute indication for surgery

Significant muscle weakness

Progressive neurological deficit with bed rest

Bowel or bladder dysfunction


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Disc Herniation

Relative indication for surgery

Pain despite bed rest

Recurrent episodes of severe pain


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SEARisk Factor

IVDA

Diabetes

Trauma

Prior spinal surgery or nerve blocks

Immune compromised host


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SEAPresenting Complaints

Back pain

Paresthesias

Motor deficits

Fever


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SEADiagnosis

WBC

Sedimentation Rate

MRI = gold standard


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SEAOrganisms

Staphylococcus aureus

- Methicillin resistant – 15%

Streptococcus

Escherichia coli

Pseudomonas

Klebsiella

Mycobacterium Tuberculosis


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SEATreatment

Surgery – depending on

severity of neuro deficits

Extent of spine involved

Infecting organism

Antibiotics


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SEANon-Operative Indications

Panspinal involvement

Lumbosacral SEA and normal neuro exam

Fixed neuro deficit for > 48 hours


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SEAAntibiotics

Start immediately

Vancomycin

Aminoglycoside or 3rd generation cephalosporin

4 to 6 weeks


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Spinal Epidural Hematoma (SEH)Risk Factors

Coagulapathy

Trauma

Vascular lesion

Surgery

Epidural catheterization


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SEHDiagnosis

Back pain, neuro deficit

Symptom onset to max. neuro deficit = 13 hours

All segments of spinal cord

MRI = gold standard

Plain X-ray or CT scan for fractures or dislocation


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SEHTreatment

Surgical evacuation

Immediate surgery within 12 hours of presentation had better outcome than later surgery


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The Case

MRI is done which confirms a compressive lesion from L2 to L4. WBC = 18,000. The patient is given antibiotics and is admitted to neurosurgery. An L3-L4 laminectomy is done and pus is drained.

Organism= Streptococcus and Stomatococcus mucilaginosis

Patient was discharged to a rehab facility on hospital day 13 for 6 weeks of Vancomycin therapy. At the time of discharge he was continent, but could only ambulate with assisted use of a walker.


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Conclusion

Back pain is common in the ED

Radicular pain requires diligence to find the cause

The severity of spinal cord compression is related to force, duration and rate

Emergent therapy is necessary

“Spinal Cord Attack”


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First line of therapy for epidural spinal cord compression from metastatic cancer is:

A.Radiation therapy

B.Surgery

C.Corticosteroids

D.Chemotherapy


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The most common site of epidural spinal cord compression from metastatic cancer is:

A.Cervical spine

B.Thoracic spine

C.Lumbar spine

D.Sacral spine


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All of the following are indications for non-operative treatment of spinal epidural abscesses except:

A.Pan-spinal involvement

B.Lumbosacral SEA and normal neurological exam

C.Fixed neurological deficits for greater than 48 hrs

D.Urinary incontinence and sensory deficit


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All of the following contribute to the severity of spinal cord compression except:

A.Force of compression

B.Length of spinal cord compressed

C.Duration of compression

D.Rate of compression


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The most common organism cultured in spinal epidural abscesses is:

A.Streptococcus

B.Pseudomonas

C.Staphylococcus aureus

D.Klebsiella

E.Mycobacterium tuberculosis


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