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The Challenge Of Acute Back Pain

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

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