The Challenge Of Acute Back Pain


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The Challenge Of Acute Back Pain

  1. 1. The Challenge of Acute Back Pain Emergency Department, WanFang Hospital Ping Hsun, Lee
  2. 2. Introduction <ul><li>Back pain is one of the most common symptoms that brings patients to the ED </li></ul><ul><li>Elderly patient with back pain and osteophyte </li></ul><ul><li>Young athlete with pain caused by back trauma </li></ul><ul><li>Cannot miss diagnoses </li></ul><ul><li>0.7% - spinal malignancy </li></ul><ul><li>0.01% - spinal infections </li></ul>
  3. 3. The Diagnostic Imperative <ul><li>Correctly diagnose </li></ul><ul><li>- Minimizing expensive diagnostic testing </li></ul><ul><li>1. Is there likely to be a serious systemic disease causing the pain? </li></ul><ul><li>2. Does the patient have a neurologic disease requiring neuro-surgical evaluation? </li></ul><ul><li>3. Is there psychological stress that might be excerbating the patient's condition? </li></ul>
  4. 4. The Diagnostic Imperative <ul><li>1. Those patients with serious spinal conditions. </li></ul><ul><li>2. Those patients with sciatica, suggesting nerve root compression. </li></ul><ul><li>3. Those patients with non-specific symptoms who fit into neither of the above categories. </li></ul>
  5. 5. Patient Satisfaction <ul><li>Providing a likely diagnosis </li></ul><ul><li>A discussion of maneuvers that will restore functional status </li></ul><ul><li>A brief explanation </li></ul><ul><li>A plan directed at pain management </li></ul>
  6. 6. Anatomic and Physiological Considerations <ul><li>Clinical anatomy is essential for diagnostic purposes </li></ul><ul><li>Anteriorly - vertebral bodies </li></ul><ul><li>Laterally - pedicles and transverse process </li></ul><ul><li>Posterior - laminae and spinous processes </li></ul><ul><li>The spinal cord itself ends at the L 1 -L 2 interspace </li></ul>
  7. 7. Anatomic and Physiological Considerations <ul><li>Intervertebral disks are a common site for back pain-related pathology </li></ul><ul><li>The pressure within the disks increases with cough, straining, bending, and sitting </li></ul><ul><li>These disks often begin to degenerate at about 30 y/o </li></ul><ul><li>Most often posterolaterally </li></ul>
  8. 8. Anatomic and Physiological Considerations <ul><li>The epidural space lies between the vertebral periosteum and the dura that envelops the </li></ul><ul><li>- Fat </li></ul><ul><li>- Connective tissue </li></ul><ul><li>- Extensive venous plexus </li></ul><ul><li>Requires about a 50% reduction in the A-P diameter of the spinal canal to produce neurological symptoms </li></ul>
  9. 9. Differential Diagnosis <ul><li>Spinal causes </li></ul><ul><li>Central disk herniation </li></ul><ul><li>Tumor </li></ul><ul><li>Infection: vertebral osteomyelitis, epidural abscess, brucellosis, </li></ul><ul><li>Tuberculosis </li></ul><ul><li>Epidural hematoma </li></ul><ul><li>Transverse myelitis </li></ul><ul><li>Ankylosing spondylitis </li></ul><ul><li>Spinal stenosis </li></ul>
  10. 10. Differential Diagnosis <ul><li>Abdominal causes </li></ul><ul><li>Billiary disease: cholecystitis, pancreatitis </li></ul><ul><li>GI: posterior penetrating ulcer, esophageal disease </li></ul><ul><li>GYN disease: ovarian torsion, mass, abscess </li></ul><ul><li>Retroperitoneal causes </li></ul><ul><li>Vascular: AAA, dissection, RPH </li></ul><ul><li>Renal: stone, tumor, abscess, obstruction </li></ul><ul><li>Pancreatic: abscess, pancreatitis, mass </li></ul>
  11. 11. Differential Diagnosis <ul><li>Pulmonary causes </li></ul><ul><li>Any process inflaming the posterior parietal pleura: tumor, infarction, infection, pleurisy </li></ul><ul><li>Systemic causes </li></ul><ul><li>Endocarditis and bacteremia </li></ul><ul><li>Transfusion reactions </li></ul>
  12. 12. Clinical Approach <ul><li>Sudden onset of acute back pain in an older patient </li></ul><ul><li>History of cancer </li></ul><ul><li>Elder patient with hypertension </li></ul><ul><li>History of a known aortic aneurysm </li></ul><ul><li>History of peptic ulcer disease </li></ul><ul><li>Medication history </li></ul><ul><li>Recent back surgery </li></ul>
  13. 13. Clinical Approach <ul><li>History taking </li></ul><ul><li>- Onset of pain </li></ul><ul><li>- Duration </li></ul><ul><li>- Character </li></ul><ul><li>- Factors that exacerbate or ameliorate the pain </li></ul><ul><li>- Trauma history </li></ul><ul><li>- Fever or chills </li></ul><ul><li>- Back that worse at night or with rest </li></ul><ul><li>- Radiation of pain </li></ul>
  14. 14. Clinical Approach <ul><li>Abdomen </li></ul><ul><li>- Unilateral distribution </li></ul><ul><li>- Bilateral </li></ul><ul><li>Social history </li></ul>
  15. 15. Physical Examination <ul><li>Careful and meticulous neurological examination of the lower extremities </li></ul><ul><li>The back should be inspected for ecchymosis and deformity </li></ul><ul><li>Range of motion </li></ul><ul><li>Straight leg raise test </li></ul>
  16. 16. Physical Examination <ul><li>About 95-98% of all lumbar disk herniations involve the L 5 and S 1 roots </li></ul><ul><li>The majority of other herniations affect the L 3 and L 4 roots (the femoral nerve) </li></ul>
  17. 17. Physical Examination <ul><li>L 3 -L 4 lesion - decreased strength of knee extension </li></ul><ul><li>- decreased sensation of the medial knee </li></ul><ul><li>- a compromised knee reflex </li></ul><ul><li>L 5 lesion - impaired extension of the great toe </li></ul><ul><li> - decreased sensation of the first dorsal web space </li></ul><ul><li> - no reflex changes </li></ul><ul><li>S 1 lesion - weakened plantar flexion of the foot </li></ul><ul><li> - decreased sensation in the lateral aspect of the fifth toe </li></ul><ul><li> - decreased or absent ankle jerk </li></ul>
  18. 18. Physical Examination <ul><li>Rectal examination is usually useful and essential in </li></ul><ul><li>- those with extreme pain </li></ul><ul><li>- whose history suggests sphincter abnormalities </li></ul><ul><li>- those with any abnormality found by neurological examination </li></ul><ul><li>- those at risk for serious, “cannot-miss” diagnoses </li></ul><ul><li>Urinary retention (90%) </li></ul><ul><li>Diminished anal sphincter tone (70%) </li></ul><ul><li>Assessing the ability of the patient with back pain to ambulate </li></ul>
  19. 19. Laboratory and Radiographic Studies <ul><li>Presence of neurological abnormalities </li></ul><ul><li>Known malignant disease </li></ul><ul><li>HIV infection or other immunocompromise </li></ul><ul><li>Elderly patient with progressive systemic symptoms </li></ul>
  20. 20. Laboratory and Radiographic Studies <ul><li>Urinalysis </li></ul><ul><li>Complete blood count </li></ul><ul><li>Erythrocyte sedimentation rate </li></ul><ul><li>Calcium </li></ul><ul><li>Alkaline phosphatase levels </li></ul>
  21. 21. Laboratory and Radiographic Studies <ul><li>Plain films </li></ul><ul><li>Radionuclide scans </li></ul><ul><li>CT scans </li></ul><ul><li>MR scans </li></ul><ul><li>Myelography </li></ul><ul><li>Bone scans </li></ul>
  22. 22. Risk Stratification for Imaging <ul><li>Duration > 4 weeks </li></ul><ul><li>Failure of conservative therapy or increasing symptoms during conservative therapy </li></ul><ul><li>Bilateral radicular symptoms </li></ul><ul><li>Focal lower extremity weakness (recent use of walking aid, frequent falls) </li></ul><ul><li>History of malignancy (or suspicion of recent non-intensional weight loss) </li></ul><ul><li>HIV infection with CD4 counts of < 200 </li></ul>
  23. 23. Risk Stratification for Imaging <ul><li>Urinary urgency or loss of sphincter control </li></ul><ul><li>Fever (without alternative source) , recent infections </li></ul><ul><li>Claudication (neurogenic or vascular) </li></ul><ul><li>Drug history </li></ul><ul><li>immunosuppressive drugs or chronic steroids </li></ul><ul><li>IVDA </li></ul><ul><li>anticoagulation with INR > 3.0 </li></ul><ul><li>Recent back surgery or spinal anesthesia and on anticoagulants </li></ul>
  24. 24. Risk Stratification for Imaging <ul><li>Fever (without alternative source) </li></ul><ul><li>Abdominal mass or tenderness </li></ul><ul><li>Abnormal neurological findings </li></ul><ul><li>- cord lesion </li></ul><ul><li>- cauda equina lesion </li></ul><ul><li>- nerve plexus lesion </li></ul><ul><li>- nerve root (radicular) lesion </li></ul>
  25. 25. Simple and Mechanical Cause <ul><li>The most non-traumatic low back pain are musculoskeletal origin </li></ul><ul><li>Only a few percent of which are sciatica </li></ul><ul><li>Benign natural history </li></ul>
  26. 26. Simple and Mechanical Cause <ul><li>Highly selective imaging in patients with back pain </li></ul><ul><li>The clinician should explain that based on a careful history and physical examination, that there is nothing to suggest a serious cause of the back pain </li></ul><ul><li>The physician should explain that plain X-rays frequently do not show the relevant structures that may be causing back pain </li></ul><ul><li>That MR scanning, while it will show those details, is so snesitive that it often shows potentially misleading abnormalities </li></ul>
  27. 27. Simple and Mechanical Cause <ul><li>Traditionally, bed rest has been the cornerstone of therapy for simple, mechanical low back pain or a herniated disk without neuromotor signs </li></ul><ul><li>Continuation of normal activities as tolerated had a more rapid recovery </li></ul><ul><li>Strenuous activities or heavy lifting, even if “normal” for an individual patient, should be limited </li></ul><ul><li>Prolong sitting may cause increased discomfort </li></ul><ul><li>If bed reat is prescribed, it should be only for a short period </li></ul>
  28. 28. Simple and Mechanical Cause <ul><li>Acetaminophen </li></ul><ul><li>Aspirin </li></ul><ul><li>Other NSAIDs </li></ul><ul><li>COX-2 inhibitor </li></ul><ul><li>Muscle relaxants </li></ul><ul><li>Injections of facet joints and trigger points </li></ul><ul><li>Physical manipulation </li></ul><ul><li>Epidural injections </li></ul>
  29. 29. Simple and Mechanical Cause <ul><li>Despite documented success with conservative therapy, the occasional patient with a herniated disk will require surgery </li></ul><ul><li>- Sciatica is both severe and disabling </li></ul><ul><li>- Symptoms of sciatica persist without improvement or show progression </li></ul><ul><li>- Clinical evidence of nerve compromise </li></ul>
  30. 30. “ Cannot Miss” Conditions <ul><li>Non-spinal causes </li></ul><ul><li>- aortic dissection </li></ul><ul><li>- expansion or rupture of an abdominal aortic aneurysm </li></ul><ul><li>- abdominal disease </li></ul><ul><li>Disk herniation </li></ul><ul><li>- the vast majority of herniated disk rupture posterolaterally </li></ul><ul><li>- fewer than 1% displace directly posteriorly (or centrally) </li></ul>
  31. 31. Disk Herniation <ul><li>Cauda equina syndrome </li></ul><ul><li>- back and bilateral leg pain, numbness </li></ul><ul><li>- sphincter dysfunction </li></ul><ul><li>Urinary retention (90%) </li></ul><ul><li>Anal sphincter dysfunction (70%) </li></ul><ul><li>Anesthesia of the perineum (saddle anesthesia) and of the posteromedial thigh (75%) </li></ul><ul><li>Patient who rapidly develop neurologic dysfunction must be decompressed surgically </li></ul>
  32. 32. Ankylosing Spondylitis <ul><li>Young male </li></ul><ul><li>Slowly progressive back ache and stiffness </li></ul><ul><li>Worse in the morning and improves over the course of the day </li></ul><ul><li>Gradually, these patients develop diminished ROM of the back </li></ul><ul><li>PE reveals diminished excursion of the lumbar spine and chest </li></ul><ul><li>Plain film </li></ul><ul><li>ESR </li></ul>
  33. 33. Abdominal Aortic Aneurysm <ul><li>Older, hypertensive patients </li></ul><ul><li>Back pain, high blood pressure, and a pulsatile abdominal mass </li></ul><ul><li>Shock </li></ul><ul><li>Differential diagnosis </li></ul><ul><li>- Osteoarthritic back pain </li></ul><ul><li>- Renal colic </li></ul><ul><li>- Acute diverticulitis </li></ul><ul><li>- GI bleeding </li></ul>
  34. 34. Abdominal Aortic Aneurysm <ul><li>The abdominal examination is highly unreliable for diagnosing an AAA </li></ul><ul><li>Abdominal bruit </li></ul><ul><li>An AAA generally can be palpated above the umbilicus and to the right of the midline </li></ul><ul><li>When palpation of the aorta reveals lateral displacement of the pulse wave, AAA should be suspected </li></ul><ul><li>Diminished lower extremity pulses </li></ul><ul><li>Peripheral emboli or arterial occlusive disease </li></ul>
  35. 35. Abdominal Aortic Aneurysm <ul><li>> 80% of patients who present with ruptured aneurysms have never been diagnosed as having an AAA </li></ul><ul><li>Abdominal, flank, or back pain are the most common symptoms in patients with a rapidly expanding or ruptured AAA </li></ul><ul><li>Syncope </li></ul><ul><li>A pulsatile abdominal mass </li></ul>
  36. 36. Abdominal Aortic Aneurysm <ul><li>Ultrasonography </li></ul><ul><li>- 100% sensitive </li></ul><ul><li>- noninvasive </li></ul><ul><li>- relatively inexpensive </li></ul><ul><li>- distinguish free intraperitoneal blood </li></ul><ul><li>- aneurysmal rupture </li></ul><ul><li>- complications evluation </li></ul><ul><li>- thoracic or suprarenal aorta </li></ul>
  37. 37. Abdominal Aortic Aneurysm <ul><li>CT scan </li></ul><ul><li>- able to measure the size </li></ul><ul><li>- show the full anatomic involvement </li></ul><ul><li>- aortic lumen size </li></ul><ul><li>- presence of mural thrombus </li></ul><ul><li>- hematoma (from rupture) </li></ul><ul><li>- dissection </li></ul><ul><li>- retroperitoneal structures </li></ul>
  38. 38. Abdominal Aortic Aneurysm <ul><li>Patient in whom AAA is strongly suspected must be managed in a rapid, directed manner </li></ul><ul><li>To stabilize and monitor the patient’s hemodynamic status </li></ul><ul><li>Surgical and radiological consultation </li></ul><ul><li>Unstable patients should be taken directly to the operation room </li></ul>
  39. 39. Infections of the Spine and Spinal Canal <ul><li>Vertebral Osteomyelitis </li></ul><ul><li>Epidural abscess </li></ul><ul><li>Intra-medullary abscess </li></ul><ul><li>Early diagnosis and definitive therapy </li></ul>
  40. 40. Vertebral Osteomyelitis <ul><li>The vertebral bodies have a rich, but sluggish blood supply </li></ul><ul><li>One artery supplies two vertebrae along with the interventing disk </li></ul><ul><li>Vertebral osteomyelitis of the spine typically involve two adjacent vertebral bodies </li></ul><ul><li>Tumor infiltration may involve only a single vertebral body </li></ul><ul><li>Vertebral osteomyelitis can develop from hematogenous or contiguous spread of infection </li></ul>
  41. 41. Vertebral Osteomyelitis <ul><li>Back pain </li></ul><ul><li>Fever (50%) </li></ul><ul><li>Radicular pain, including hip pain </li></ul><ul><li>Dysphagia, pleural effusions </li></ul><ul><li>Spinal tenderness </li></ul><ul><li>Diminished ROM </li></ul><ul><li>Positive straight leg raising test </li></ul>
  42. 42. Vertebral Osteomyelitis <ul><li>Because this process usually involves the anterior vertebral body, the back pain can percede onset of neurologic findings by some time </li></ul><ul><li>Pyogenic vertebral osteomyelitis of the posterior elements has been reported but is far less common </li></ul><ul><li>Staphylococcus aureus is the most common offending organism </li></ul><ul><li>Gram-negative enteric species </li></ul><ul><li>Salmonella </li></ul><ul><li>Tuberculosis, brucellosis </li></ul>
  43. 43. Vertebral Osteomyelitis <ul><li>Bacterial cases </li></ul><ul><li>- lumbar (50%) </li></ul><ul><li>- thoracic (35%) </li></ul><ul><li>- cervical (15%) </li></ul><ul><li>Tuberculous cases are much more common in the thoracic spine </li></ul><ul><li>Plain films are abnormal in as many as 95% of cases </li></ul><ul><li>MR scanning </li></ul>
  44. 44. Epidural Abscess <ul><li>Vertebral osteomyelitis </li></ul><ul><li>Genitourinary infections </li></ul><ul><li>Soft-tissue infections </li></ul><ul><li>Epidural anesthesia </li></ul><ul><li>Back surgery </li></ul><ul><li>Trauma </li></ul><ul><li>Diabetes </li></ul><ul><li>IVDA </li></ul><ul><li>Alcoholism </li></ul>
  45. 45. Epidural Abscess <ul><li>Back pain </li></ul><ul><li>Radicular pain </li></ul><ul><li>Motor, sensory, sphincter symptoms </li></ul><ul><li>Back (or neck) stiffness </li></ul><ul><li>Fever (75%) </li></ul><ul><li>Spinal tenderness </li></ul><ul><li>Normal neurological examination (approximately 50%) </li></ul>
  46. 46. Epidural Abscess <ul><li>WBC > 11000 (less than 70%) </li></ul><ul><li>ESR </li></ul><ul><li>Positive blood culture (60%) </li></ul><ul><li>Staphylococcus aureus is by far the most common organism </li></ul><ul><li>Streptococcal and gram-negative enteric organism </li></ul><ul><li>Cervical location is not uncommon </li></ul><ul><li>Usually extends over multiple vertebral segments (> 4) </li></ul><ul><li>Plain X-ray are positive in 44 - 65% of cases </li></ul>
  47. 47. Epidural Abscess <ul><li>Intravenous antibiotics </li></ul><ul><li>Surgical decompression </li></ul><ul><li>Early neurosurgical consultation is important </li></ul><ul><li>Patient outcome are largely a function of the neurologic condition at the time of presentation and duration of neurological deficits prior to examination </li></ul><ul><li>Mortality rate: 5 - 23% </li></ul>
  48. 48. Spinal Cancer <ul><li>Metastatic disease in the spine </li></ul><ul><li>Lung cancer </li></ul><ul><li>Breast cancer </li></ul><ul><li>Prostate cancer </li></ul><ul><li>Lymphoma </li></ul><ul><li>Renal cell carcinoma </li></ul><ul><li>Melanoma </li></ul><ul><li>Sarcoma </li></ul><ul><li>Multiple myeloma </li></ul><ul><li>Thyroid cancer </li></ul>
  49. 49. Spinal Cancer <ul><li>Among cases of metastatic bone involvement, the spine is the most commonly involved site </li></ul><ul><li>The vertebral body is usually involved first </li></ul><ul><li>Direct epidural extension (85%) </li></ul><ul><li>Radiographic evidence of vertebral metastatic disease can be a late event </li></ul>
  50. 50. Spinal Cancer <ul><li>Thoracic location is most common (60 - 70%) </li></ul><ul><li>Prostate and colon cancer tend to spread to the lumbar area </li></ul><ul><li>Lung cancer preferentially affect the thoracic spine </li></ul><ul><li>Breast and prostate cancer tend to spread multiple areas </li></ul><ul><li>The rate of development of compression </li></ul>
  51. 51. Spinal Cancer <ul><li>Pain (back pain to radicular pain to neurological signs) </li></ul><ul><li>The pain produced by spinal metastatic disease is similar to herniated disk </li></ul><ul><li>SLR test </li></ul><ul><li>Cancer pain can occur at any area in the spine </li></ul><ul><li>Pain from cancer tends to be unaffected or worse with rest or at night </li></ul><ul><li>Delayed diagnosis </li></ul>
  52. 52. Spinal Cancer <ul><li>For patient with neurological findings, MR scanning is clearly indicated, the only issue being how urgent </li></ul><ul><li>Knowledge of the primary tumor </li></ul><ul><li>Proceeding to MR scanning directly as the best policy </li></ul><ul><li>25% of cancer patients whose symptoms or signs suggest radiculopathy, and who have normal plain films, have metastatic epidural cord compression </li></ul><ul><li>Conventional CT scan or myelography </li></ul>
  53. 53. Spinal Cancer <ul><li>Patients with signs of cord or cauda equina lesion should be imaged within hours </li></ul><ul><li>Those with root or plexus lesions and with isolated back pain can be imaged urgently, preferably within 24 hours </li></ul><ul><li>Consultation with the patient’s oncologist, as well as with a radiation oncologist and neurosurgeon </li></ul><ul><li>Steroids and radiation therapy </li></ul><ul><li>Decompressive surgery </li></ul>
  54. 54. Spinal Hematomas <ul><li>Rare but serious disease </li></ul><ul><li>Peak incidence between 50 and 80 years of age </li></ul><ul><li>Posterolateral in location </li></ul><ul><li>Rupture of veins in the spinal epidural plexus </li></ul><ul><li>Anticoagulation </li></ul><ul><li>Recent spinal surgery </li></ul><ul><li>Spinal anesthesia </li></ul><ul><li>Lumbar puncture </li></ul>
  55. 55. Back Pain in the Elderly <ul><li>Patients older than the age of 50 years have a higher incidence of “cannon miss” diagnoses </li></ul><ul><li>Herniated disk is less common </li></ul><ul><li>Age older than 70 as a risk factor for spinal fracture </li></ul><ul><li>Spinal stenosis </li></ul><ul><li>- central canal diameter less than 11mm </li></ul><ul><li>- lateral recesses depth less than 3mm </li></ul><ul><li>- hypertrophic soft tissue </li></ul><ul><li>- bony degenerative change </li></ul>
  56. 56. Spinal Stenosis <ul><li>Neurogenic claudication (60 - 100%) </li></ul><ul><li>- pain in the legs </li></ul><ul><li>- with or without neurologic symptoms (especially paresthesias) </li></ul><ul><li>- occur with walking, exercise in the erect posture, even standing </li></ul><ul><li>Indication for surgery </li></ul><ul><li>- increasing symptoms </li></ul><ul><li>- incapacitation </li></ul>
  57. 57. Osteoarthritis <ul><li>The clinician must always consider osteoarthritis in the differential diagnosis of elderly patients presenting to the ED </li></ul><ul><li>Osteoarthritis is the most commonly diagnosed joint disorder in the elderly population </li></ul><ul><li>Radiographic criteria </li></ul><ul><li>- joint space narrowing </li></ul><ul><li>- bony sclerosis </li></ul><ul><li>- cyst formation </li></ul><ul><li>- osteophyte formation </li></ul>
  58. 58. Osteoarthritis <ul><li>Primary and secondary </li></ul><ul><li>Final common pathway </li></ul><ul><li>More prevalent symptomatically in female </li></ul><ul><li>Secondary osteoarthritis </li></ul><ul><li>- mechanical </li></ul><ul><li>- congenital </li></ul><ul><li>- development disorder </li></ul><ul><li>- systemic disease </li></ul>
  59. 59. Osteoarthritis <ul><li>Historical support and radiographic confirmation of osteophytes </li></ul><ul><li>Joint pain </li></ul><ul><li>Pain with use and relief with rest </li></ul><ul><li>The pain is usually aching and will progress to chronic pain </li></ul><ul><li>Insidious and usually takes months to years to develop </li></ul><ul><li>Monoarticular in its early presentation </li></ul><ul><li>Involvement of the wrist, shoulder, or elbow is uncommon </li></ul>
  60. 60. Osteoarthritis <ul><li>Pain management </li></ul><ul><li>Functional improvement </li></ul><ul><li>Acetaminophen </li></ul><ul><li>NSAIDs (Ibuprofen, Napoxen) </li></ul><ul><li>COX-2 inhibitor (Celecoxib, Rofecoxib) </li></ul>
  61. 61. Neuro-Imaging of Back Pain Patients Low Risk <ul><li>Patients with none of the high-risk criteria </li></ul><ul><li>No imaging studies needs </li></ul><ul><li>Patient education </li></ul><ul><li>- Thorough explanation of medical decision making prognosis with realistic time course (3-6 weeks) explanation of why imaging studies are not indicated </li></ul><ul><li>Treatment </li></ul><ul><li>- non-narcotic analgesia </li></ul><ul><li>- consider physical therapy, heat, cold, other </li></ul><ul><li>- early return to routine activities </li></ul><ul><li>- delayed exercise of back, abdomen </li></ul><ul><li>Follow-Up </li></ul><ul><li>- With PCP if not improving as expected </li></ul>
  62. 62. Neuro-Imaging of Back Pain Patients Medium Risk <ul><li>Risk factors plus normal exam </li></ul><ul><li>Risk factors plus exam showing root or plexus lesion </li></ul><ul><li>MRI done urgently (< 24 hours) </li></ul><ul><li>MRI negative </li></ul><ul><li>- careful follow-up by PCP </li></ul><ul><li>- consultation as appropriate </li></ul><ul><li>MRI positive </li></ul><ul><li>- treatment and consultation appropriate for diagnosis </li></ul>
  63. 63. Neuro-Imaging of Back Pain Patients High Risk <ul><li>Exam shows cord or cauda equina lesion </li></ul><ul><li>Fever and suspicion of epidural abscess or hematoma </li></ul><ul><li>Abdominal exam suggest AAA </li></ul><ul><li>Urinary urgency or sphincter symptoms </li></ul><ul><li>MRI done emergently (within several hours) </li></ul><ul><li>MRI (or other imaging study) negative </li></ul><ul><li>- consultation to determine etiology of symptoms and signs </li></ul><ul><li>MRI (or other imaging study) positive </li></ul><ul><li>- treatment and consultation appropriate for diagnosis </li></ul>
  64. 64. Summary and Diagnostic Algorithm <ul><li>To identify the vast majority of back pain patients with serious disease </li></ul><ul><li>Simultaneously avoiding unnecessary imaging studies </li></ul><ul><li>Whatever algorithm is chosen, the emergency physician must remain alert for patients whose back pain falls into the </li></ul><ul><li>“ cannot miss” group </li></ul>
  65. 65. Thank You!