Educational Objectives - University of Illinois at Chicago

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					               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
•   Treatment options for patients with back
    pain and neurological findings


                            Brad Bunney, MD
                      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
                                      Brad Bunney, MD
What do you want to do?
                       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?

                                      Brad Bunney, MD
                      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?              Brad Bunney, MD
              Epidemiology


•   60-90% experience back pain in lifetime
•   5 million disabled
•   No definitive diagnoses in 80%
•   90% get better no matter therapy


                           Brad Bunney, MD
                  Anatomy


•   Vertebra – body, neural arch, bony process
•   Ligaments & muscles = stability
•   Cervical nerve roots pass above body
•   All others pass below


                             Brad Bunney, MD
Types of Back Pain


  •   Local
  •   Referred
  •   Radicular



                  Brad Bunney, MD
          Types of Back Pain
                Local


•   Irritation of bone, muscle, joints
•   Steady, sharp or dull
•   Worse with movement



                            Brad Bunney, MD
             Types of Back Pain
                 Referred


•   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
                              Brad Bunney, MD
           Types of Back Pain
               Radicular


•   Irritation of the nerve root
•   Can radiate to the calf and feet
•   Worse with movement that
    increases CSF pressure


                           Brad Bunney, MD
        Nerve Root Diagnosis
                L4

•   Pain = lateral back, antero-lateral
    thigh, anterior calf
•   Numbness = anterior thigh
•   Weakness = quadriceps
•   Diminished knee jerk
•   Squat and rise        Brad Bunney, MD
           Nerve Root Diagnosis
                   L5

•   Pain = hip, groin, postero-lateral
    thigh, lateral calf and dorsum of foot
•   Numbness = lateral calf
•   Weakness = dorsiflex great toe
•   Heel walking
                            Brad Bunney, MD
          Nerve Root Diagnosis
                  S1

•   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
                            Brad Bunney, MD
      Spinal Cord Compression

•   Malignant epidural spinal cord
    compression (MESCC)
•   Disc herniation
•   Spinal epidural abscess (SEA)
•   Spinal epidural hematoma (SEH)

                        Brad Bunney, MD
Spinal Cord Compression Factors


  •   Force of compression
  •   Direction of compression
  •   Rate of compression



                      Brad Bunney, MD
                  MESCC


•   Hematogenous spread
•   Bone marrow
•   Compress cord and vascular supply
•   Edema, infarction

                          Brad Bunney, MD
               MESCC

•   Prostate
•   Lung
•   Breast
•   Non-Hodgkin’s lymphoma
•   Multiple myeloma
•   Renal cell cancer
                        Brad Bunney, MD
                  MESCC

•   Initial presentation in 20% of
    malignancies
•   Cervical, thoracic & lumbar by
    proportion of vertebral body volume
•   Thoracic is most common

                           Brad Bunney, MD
                MESCC

•   95% have back pain
•   Precedes other symptoms by 1-2
    months
•   Percussion tendencies, thoracic
    location, worse lying down

                         Brad Bunney, MD
               MESCC

•   75% have weakness by time of
    diagnosis
•   Weakness symmetric
•   Ascending numbness
•   Autonomic dysfunction, urinary
    retention
                       Brad Bunney, MD
                 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


                          Brad Bunney, MD
                 MESCC


•   Corticosteroids first line for edema
•   Dexamethosone, 20-100 mg load, 4-
    24 mg 4 times/day
•   Radiation therapy within 24 hours


                          Brad Bunney, MD
                MESCC


•   Surgery for:
    - unresponsive to radiation therapy
    - Acute neurological deteriorations
•   Chemotherapy – Non-Hodgkin’s
    lymphoma
                          Brad Bunney, MD
            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
                         Brad Bunney, MD
              Disc Herniation


•   Not necessary to have history of
    strain or injury
•   Unilateral radicular back pain with
    nerve root impingement


                          Brad Bunney, MD
            Disc Herniation


•   X-ray only good if inter-vertebral
    disc is narrow
•   MRI is gold standard
•   Electromyelography localizes the
    specific nerve root
                           Brad Bunney, MD
            Disc Herniation


•   Initial therapy is to decrease
    pressure on the root
•   Bed rest up to 4 weeks
•   Non-steroid anti-inflammatory
•   Muscle relaxants
                           Brad Bunney, MD
               Disc Herniation

•   Absolute indication for surgery
    - Significant muscle weakness
    - Progressive neurological deficit with
      bed rest
    - Bowel or bladder dysfunction

                              Brad Bunney, MD
               Disc Herniation

•   Relative indication for surgery
    - Pain despite bed rest
    - Recurrent episodes of severe pain




                              Brad Bunney, MD
                   SEA
                Risk Factor

•   IVDA
•   Diabetes
•   Trauma
•   Prior spinal surgery or nerve blocks
•   Immune compromised host
                           Brad Bunney, MD
         SEA
Presenting Complaints


  •   Back pain
  •   Paresthesias
  •   Motor deficits
  •   Fever

                  Brad Bunney, MD
             SEA
          Diagnosis



•   WBC
•   Sedimentation Rate
•   MRI = gold standard


                      Brad Bunney, MD
                  SEA
               Organisms
•   Staphylococcus aureus
    - Methicillin resistant – 15%
•   Streptococcus
•   Escherichia coli
•   Pseudomonas
•   Klebsiella
•   Mycobacterium Tuberculosis
                             Brad Bunney, MD
              SEA
           Treatment

•   Surgery – depending on
    - severity of neuro deficits
    - Extent of spine involved
    - Infecting organism
•   Antibiotics

                       Brad Bunney, MD
                SEA
       Non-Operative Indications


•   Panspinal involvement
•   Lumbosacral SEA and normal neuro
    exam
•   Fixed neuro deficit for > 48 hours


                          Brad Bunney, MD
                SEA
             Antibiotics

•   Start immediately
•   Vancomycin
•   Aminoglycoside or 3rd generation
    cephalosporin
•   4 to 6 weeks
                        Brad Bunney, MD
Spinal Epidural Hematoma (SEH)
          Risk Factors


  •   Coagulapathy
  •   Trauma
  •   Vascular lesion
  •   Surgery
  •   Epidural catheterization
                        Brad Bunney, MD
                      SEH
                   Diagnosis
•   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
                               Brad Bunney, MD
                   SEH
                Treatment

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


                            Brad Bunney, MD
                      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.


                                     Brad Bunney, MD
                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”     Brad Bunney, MD
First line of therapy for epidural spinal cord
  compression from metastatic cancer is:




        A. Radiation therapy
        B. Surgery
        C. Corticosteroids
        D. Chemotherapy




                              Brad Bunney, MD
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




                              Brad Bunney, MD
  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




                                Brad Bunney, MD
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



                                 Brad Bunney, MD
The most common organism cultured in spinal
           epidural abscesses is:



       A. Streptococcus
       B. Pseudomonas
       C. Staphylococcus aureus
       D. Klebsiella
       E. Mycobacterium tuberculosis



                            Brad Bunney, MD

				
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