ECINSW

1. ECINSW Medical Bites Back Pain E C I S - W N

2. Back Pain Lecture to go with Medical Bites

3. 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

4. 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

5. 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

6. Back PainDefinitions • Pain described by the patient or clinician as arising from the back.

7. 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 • Caudaequina( the major back emergency)

8. 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

9. 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 inone system, AND the effect of failure onother systems • If we treat immediately, we prevent further harm

10. 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

11. 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)

12. 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)

13. 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

14. 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

15. 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.)

16. 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)

17. Back PainInvestigations Bedside • 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

18. Back PainInvestigations Imaging • 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)

19. Back PainInvestigations Imaging • 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

20. Back PainInvestigations Imaging • 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

21. Back PainInvestigations Imaging • 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

22. Back PainInvestigations Imaging • 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

23. Imaging MRI may be performed as an emergency investigation where there is suspicion of caudaequina 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 PainInvestigations

24. 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

25. 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

26. 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

27. Back Pain Specifics • Cauda equina syndrome (CES) • Infection • Nerve root compression • Inflammatory and ischaemic • Musculoskeletal • Fractures • Muscular pain

28. Back Pain Specifics Cauda 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

29. Back Pain CES - pathophysiology • Compression of susceptible cauda equina nerve roots • May be caused by… • Trauma • Lumbar disc disease • Abscess • Spinal anesthesia

30. 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

31. 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

32. 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

33. 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

34. Back Pain CES - investigation Bedside • Urinalysis for infection Laboratory • FBC • WCC - investigating for infection • Hb - investigating for malignancy Imaging • Key investigations are imaging

35. Back Pain CES - investigation Imaging • 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

36. 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

37. 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

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

39. Back Pain Infection - history • Back pain which is increasing, and lasting for weeks to months • Fever is present in around 50% of patients

40. 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

41. Back Pain Infection - examination • Sensory examination includes • sensory level • heat / cold • pain • reflexes • rectal tone • perianal sensation

42. Back Pain Infection - investigation Bedside • Urinalysis - infection, diabetes, blood Laboratory • 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

43. Back Pain Infection - investigation Imaging • 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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)

50. Back Pain Nerve root compression