Low Back Pain Brad Bunney, MD Department of Emergency Medicine University of Illinois College of Med - PowerPoint PPT Presentation

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Low Back Pain Brad Bunney, MD Department of Emergency Medicine University of Illinois College of Med

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... 2 days later with worsening pain that radiates to the right foot and left knee. ... Rarely extends below the knee. Brad Bunney, MD. Types of Back Pain. Radicular ... – PowerPoint PPT presentation

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Title: Low Back Pain Brad Bunney, MD Department of Emergency Medicine University of Illinois College of Med


1
Low Back PainBrad Bunney, MDDepartment of
Emergency MedicineUniversity of Illinois College
of Medicine-ChicagoChicago, IL
2
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

3
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
  • What do you want to do?

4
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?

5
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?

6
Epidemiology
  • 60-90 experience back pain in lifetime
  • 5 million disabled
  • No definitive diagnoses in 80
  • 90 get better no matter therapy

7
Anatomy
  • Vertebra body, neural arch, bony process
  • Ligaments muscles stability
  • Cervical nerve roots pass above body
  • All others pass below

8
Types of Back Pain
  • Local
  • Referred
  • Radicular

9
Types of Back Pain Local
  • Irritation of bone, muscle, joints
  • Steady, sharp or dull
  • Worse with movement

10
Types of Back PainReferred
  • 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

11
Types of Back PainRadicular
  • Irritation of the nerve root
  • Can radiate to the calf and feet
  • Worse with movement that increases CSF pressure

12
Nerve Root DiagnosisL4
  • Pain lateral back, antero-lateral thigh,
    anterior calf
  • Numbness anterior thigh
  • Weakness quadriceps
  • Diminished knee jerk
  • Squat and rise

13
Nerve Root DiagnosisL5
  • Pain hip, groin, postero-lateral thigh, lateral
    calf and dorsum of foot
  • Numbness lateral calf
  • Weakness dorsiflex great toe
  • Heel walking

14
Nerve Root DiagnosisS1
  • 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

15
Spinal Cord Compression
  • Malignant epidural spinal cord compression
    (MESCC)
  • Disc herniation
  • Spinal epidural abscess (SEA)
  • Spinal epidural hematoma (SEH)

16
Spinal Cord Compression Factors
  • Force of compression
  • Direction of compression
  • Rate of compression

17
MESCC
  • Hematogenous spread
  • Bone marrow
  • Compress cord and vascular supply
  • Edema, infarction

18
MESCC
  • Prostate
  • Lung
  • Breast
  • Non-Hodgkins lymphoma
  • Multiple myeloma
  • Renal cell cancer

19
MESCC
  • Initial presentation in 20 of malignancies
  • Cervical, thoracic lumbar by proportion of
    vertebral body volume
  • Thoracic is most common

20
MESCC
  • 95 have back pain
  • Precedes other symptoms by 1-2 months
  • Percussion tendencies, thoracic location, worse
    lying down

21
MESCC
  • 75 have weakness by time of diagnosis
  • Weakness symmetric
  • Ascending numbness
  • Autonomic dysfunction, urinary retention

22
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

23
MESCC
  • Corticosteroids first line for edema
  • Dexamethosone, 20-100 mg load, 4-24 mg 4
    times/day
  • Radiation therapy within 24 hours

24
MESCC
  • Surgery for
  • unresponsive to radiation therapy
  • Acute neurological deteriorations
  • Chemotherapy Non-Hodgkins lymphoma

25
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

26
Disc Herniation
  • Not necessary to have history of strain or injury
  • Unilateral radicular back pain with nerve root
    impingement

27
Disc Herniation
  • X-ray only good if inter-vertebral disc is narrow
  • MRI is gold standard
  • Electromyelography localizes the specific nerve
    root

28
Disc Herniation
  • Initial therapy is to decrease pressure on the
    root
  • Bed rest up to 4 weeks
  • Non-steroid anti-inflammatory
  • Muscle relaxants

29
Disc Herniation
  • Absolute indication for surgery
  • Significant muscle weakness
  • Progressive neurological deficit with bed rest
  • Bowel or bladder dysfunction

30
Disc Herniation
  • Relative indication for surgery
  • Pain despite bed rest
  • Recurrent episodes of severe pain

31
SEARisk Factor
  • IVDA
  • Diabetes
  • Trauma
  • Prior spinal surgery or nerve blocks
  • Immune compromised host

32
SEAPresenting Complaints
  • Back pain
  • Paresthesias
  • Motor deficits
  • Fever

33
SEADiagnosis
  • WBC
  • Sedimentation Rate
  • MRI gold standard

34
SEAOrganisms
  • Staphylococcus aureus
  • - Methicillin resistant 15
  • Streptococcus
  • Escherichia coli
  • Pseudomonas
  • Klebsiella
  • Mycobacterium Tuberculosis

35
SEATreatment
  • Surgery depending on
  • severity of neuro deficits
  • Extent of spine involved
  • Infecting organism
  • Antibiotics

36
SEANon-Operative Indications
  • Panspinal involvement
  • Lumbosacral SEA and normal neuro exam
  • Fixed neuro deficit for gt 48 hours

37
SEAAntibiotics
  • Start immediately
  • Vancomycin
  • Aminoglycoside or 3rd generation cephalosporin
  • 4 to 6 weeks

38
Spinal Epidural Hematoma (SEH)Risk Factors
  • Coagulapathy
  • Trauma
  • Vascular lesion
  • Surgery
  • Epidural catheterization

39
SEHDiagnosis
  • 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

40
SEHTreatment
  • Surgical evacuation
  • Immediate surgery within 12 hours of presentation
    had better outcome than later surgery

41
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.

42
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

43
First line of therapy for epidural spinal cord
compression from metastatic cancer is
  • A. Radiation therapy
  • B. Surgery
  • C. Corticosteroids
  • D. Chemotherapy

44
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

45
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

46
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

47
The most common organism cultured in spinal
epidural abscesses is
  • A. Streptococcus
  • B. Pseudomonas
  • C. Staphylococcus aureus
  • D. Klebsiella
  • E. Mycobacterium tuberculosis
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