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The Challenge of Acute Back The Challenge of Acute Back PainPain
Emergency Department, WanFang HospitEmergency Department, WanFang Hospitalal
Ping Hsun, LeePing Hsun, Lee
IntroductionIntroduction
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 traum
a
Cannot miss diagnoses0.7% - spinal malignancy0.01% - spinal infections
The Diagnostic The Diagnostic ImperativeImperative
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?
The Diagnostic The Diagnostic ImperativeImperative
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.
Patient SatisfactionPatient Satisfaction
Providing a likely diagnosis A discussion of maneuvers that will restore
functional status A brief explanation A plan directed at pain management
Anatomic and Physiological Anatomic and Physiological ConsiderationsConsiderations
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 L1-L2 interspa
ce
Anatomic and Physiological Anatomic and Physiological ConsiderationsConsiderations
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
Anatomic and Physiological Anatomic and Physiological ConsiderationsConsiderations
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
Differential DiagnosisDifferential Diagnosis
Spinal causesCentral disk herniationTumorInfection: vertebral osteomyelitis, epidural abscess, brucellosis, TuberculosisEpidural hematomaTransverse myelitisAnkylosing spondylitisSpinal stenosis
Differential DiagnosisDifferential Diagnosis
Abdominal causesBilliary disease: cholecystitis, pancreatitisGI: posterior penetrating ulcer, esophageal diseaseGYN disease: ovarian torsion, mass, abscess
Retroperitoneal causesVascular: AAA, dissection, RPHRenal: stone, tumor, abscess, obstructionPancreatic: abscess, pancreatitis, mass
Differential DiagnosisDifferential Diagnosis Pulmonary causes
Any process inflaming the posterior parietal pleura: tumor, infarction, infection, pleurisy
Systemic causesEndocarditis and bacteremiaTransfusion reactions
Clinical ApproachClinical 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
Clinical ApproachClinical 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
Clinical ApproachClinical Approach
Abdomen- Unilateral distribution- Bilateral
Social history
Physical ExaminationPhysical 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
Physical ExaminationPhysical Examination
About 95-98% of all lumbar disk herniations involve the L5 and S1 roots
The majority of other herniations affect the L3 and L4 roots (the femoral nerve)
Physical ExaminationPhysical Examination L3-L4 lesion - decreased strength of knee extension
- decreased sensation of the medial knee- a compromised knee reflex
L5 lesion - impaired extension of the great toe - decreased sensation of the first dorsal web space - no reflex changes
S1 lesion - weakened plantar flexion of the foot - decreased sensation in the lateral aspect
of the fifth toe - decreased or absent ankle jerk
Physical ExaminationPhysical 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
Laboratory and Laboratory and Radiographic StudiesRadiographic Studies
Presence of neurological abnormalities Known malignant disease HIV infection or other immunocompromise Elderly patient with progressive systemic sym
ptoms
Laboratory and Laboratory and Radiographic StudiesRadiographic Studies
Urinalysis Complete blood count Erythrocyte sedimentation rate Calcium Alkaline phosphatase levels
Laboratory and Laboratory and Radiographic StudiesRadiographic Studies
Plain films Radionuclide scans CT scans MR scans Myelography Bone scans
Risk Stratification for Risk Stratification for ImagingImaging
Duration > 4 weeks Failure of conservative therapy or increasing s
ymptoms during conservative therapy Bilateral radicular symptoms Focal lower extremity weakness (recent use of walki
ng aid, frequent falls) History of malignancy (or suspicion of recent non-intens
ional weight loss) HIV infection with CD4 counts of < 200
Risk Stratification for Risk Stratification for ImagingImaging
Urinary urgency or loss of sphincter control Fever (without alternative source), recent infections Claudication (neurogenic or vascular) Drug history
immunosuppressive drugs or chronic steroidsIVDAanticoagulation with INR > 3.0
Recent back surgery or spinal anesthesia and on anticoagulants
Risk Stratification for Risk Stratification for ImagingImaging
Fever (without alternative source) Abdominal mass or tenderness Abnormal neurological findings
- cord lesion- cauda equina lesion- nerve plexus lesion- nerve root (radicular) lesion
Simple and Mechanical Simple and Mechanical CauseCause
The most non-traumatic low back pain are musculoskeletal origin
Only a few percent of which are sciatica Benign natural history
Simple and Mechanical Simple and Mechanical CauseCause
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
Simple and Mechanical Simple and Mechanical CauseCause
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 sh
ort period
Simple and Mechanical Simple and Mechanical CauseCause
Acetaminophen Aspirin Other NSAIDs COX-2 inhibitor
Muscle relaxants Injections of facet joints and trigger points Physical manipulation Epidural injections
Simple and Mechanical Simple and Mechanical CauseCause
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
““Cannot Miss” Cannot Miss” ConditionsConditions
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)
Disk HerniationDisk Herniation Cauda equina syndrome
- back and bilateral leg pain, numbness- sphincter dysfunction
Urinary retention (90%) Anal sphincter dysfunction (70%) Anesthesia of the perineum (saddle anesthesi
a) and of the posteromedial thigh (75%) Patient who rapidly develop neurologic dysfun
ction must be decompressed surgically
Ankylosing SpondylitisAnkylosing 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
Abdominal Aortic Abdominal Aortic AneurysmAneurysm
Older, hypertensive patients Back pain, high blood pressure, and a pulsatile ab
dominal mass Shock
Differential diagnosis- Osteoarthritic back pain- Renal colic- Acute diverticulitis- GI bleeding
Abdominal Aortic Abdominal Aortic AneurysmAneurysm
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
Abdominal Aortic Abdominal Aortic AneurysmAneurysm
> 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
Abdominal Aortic Abdominal Aortic AneurysmAneurysm
Ultrasonography- 100% sensitive- noninvasive- relatively inexpensive- distinguish free intraperitoneal blood
- aneurysmal rupture- complications evluation- thoracic or suprarenal aorta
Abdominal Aortic Abdominal Aortic AneurysmAneurysm
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
Abdominal Aortic Abdominal Aortic AneurysmAneurysm
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 t
he operation room
Infections of the Spine and Infections of the Spine and Spinal CanalSpinal Canal
Vertebral Osteomyelitis Epidural abscess Intra-medullary abscess
Early diagnosis and definitive therapy
Vertebral OsteomyelitisVertebral Osteomyelitis The vertebral bodies have a rich, but sluggish
blood supply One artery supplies two vertebrae along with t
he interventing disk Vertebral osteomyelitis of the spine typically i
nvolve two adjacent vertebral bodies Tumor infiltration may involve only a single ve
rtebral body Vertebral osteomyelitis can develop from hem
atogenous or contiguous spread of infection
Vertebral OsteomyelitisVertebral Osteomyelitis Back pain Fever (50%) Radicular pain, including hip pain Dysphagia, pleural effusions Spinal tenderness Diminished ROM Positive straight leg raising test
Vertebral OsteomyelitisVertebral 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 organismGram-negative enteric speciesSalmonella Tuberculosis, brucellosis
Vertebral OsteomyelitisVertebral 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
Epidural AbscessEpidural Abscess Vertebral osteomyelitis Genitourinary infections Soft-tissue infections Epidural anesthesia Back surgery Trauma Diabetes IVDA Alcoholism
Epidural AbscessEpidural Abscess
Back pain Radicular pain Motor, sensory, sphincter symptoms Back (or neck) stiffness Fever (75%) Spinal tenderness Normal neurological examination (approximately 5
0%)
Epidural AbscessEpidural Abscess
WBC > 11000 (less than 70%) ESR Positive blood culture (60%) Staphylococcus aureus is by far the most common
organismStreptococcal 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
Epidural AbscessEpidural Abscess
Intravenous antibiotics Surgical decompression Early neurosurgical consultation is important Patient outcome are largely a function of the ne
urologic condition at the time of presentation and duration of neurological deficits prior to examination
Mortality rate: 5 - 23%
Spinal CancerSpinal Cancer
Metastatic disease in the spine Lung cancer
Breast cancerProstate cancerLymphomaRenal cell carcinomaMelanomaSarcomaMultiple myelomaThyroid cancer
Spinal CancerSpinal 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
Spinal CancerSpinal 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
Spinal CancerSpinal Cancer
Pain (back pain to radicular pain to neurological signs) The pain produced by spinal metastatic diseas
e 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 wo
rse with rest or at night Delayed diagnosis
Spinal CancerSpinal 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 poli
cy 25% of cancer patients whose symptoms or signs s
uggest radiculopathy, and who have normal plain films, have metastatic epidural cord compression
Conventional CT scan or myelography
Spinal CancerSpinal 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
Spinal HematomasSpinal 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
Back Pain in the ElderlyBack 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 fractur
e Spinal stenosis
- central canal diameter less than 11mm- lateral recesses depth less than 3mm- hypertrophic soft tissue- bony degenerative change
Spinal StenosisSpinal 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
OsteoarthritisOsteoarthritis
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
OsteoarthritisOsteoarthritis
Primary and secondary Final common pathway More prevalent symptomatically in female Secondary osteoarthritis
- mechanical- congenital- development disorder- systemic disease
OsteoarthritisOsteoarthritis Historical support and radiographic confirmation of o
steophytes 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 develo
p Monoarticular in its early presentation Involvement of the wrist, shoulder, or elbow is uncom
mon
OsteoarthritisOsteoarthritis
Pain management Functional improvement Acetaminophen
NSAIDs (Ibuprofen, Napoxen)COX-2 inhibitor (Celecoxib, Rofecoxib)
Neuro-Imaging of Back Pain PatieNeuro-Imaging of Back Pain Patientsnts
Low RiskLow 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
Neuro-Imaging of Back Pain PatieNeuro-Imaging of Back Pain Patientsnts
Medium RiskMedium 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
Neuro-Imaging of Back Pain PatieNeuro-Imaging of Back Pain Patientsnts
High RiskHigh Risk Exam shows cord or cauda equina lesion
Fever and suspicion of epidural abscess or hematomaAbdominal exam suggest AAAUrinary 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
Summary and Diagnostic Summary and Diagnostic AlgorithmAlgorithm
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
Thank Thank You!You!