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Back Pain Emergencies: what you cant afford to miss

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Back pain is the fifth leading reason for medical office visits in the US and ... Of the patients who have acute back pain, 90% to 95% have a non life-threatening ... – PowerPoint PPT presentation

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Title: Back Pain Emergencies: what you cant afford to miss


1
Back Pain Emergencies what you cant afford to
miss
Meghan Rothenberger, MD March, 2007
2
Background
  • In the US, up to 90 of adults will experience an
    episode of back pain during their lifetime.
  • Back pain is the fifth leading reason for medical
    office visits in the US and the leading cause of
    work-related disability.
  • Of the patients who have acute back pain, 90 to
    95 have a nonlife-threatening condition and
    although up to 85 cannot be given an exact
    diagnosis, nearly all recover within 4 to 6
    weeks.

3
Background
  • In 5 to 10 of patients, acute back pain is a
    manifestation of more serious pathology such as
  • - Vascular catastrophe (AAA, aortic
    dissection)
  • - Malignancy
  • - Spinal cord compressive syndromes
  • - Infectious disease processes (epidural
    abscess, vertebral

  • osteomyelitis)
  • Although these conditions account for a small
    percentage of causes of back pain, all are
    potentially life threatening and require rapid
    diagnosis.
  • When the diagnosis is missed or even delayed,
    patients incur substantially higher morbidity and
    mortality.

4
History
  • A detailed history is vital.
  • Pay special attention to the these RED FLAGS
  • Gradual onset of back pain
  • Age lt20 years or gt50 years
  • Isolated Thoracic back pain
  • Pain lasting gt 6 weeks
  • History of trauma
  • Fever/chills/night sweats
  • Unintentional weight loss
  • History of intravenous drug use
  • Pain worse with recumbency
  • Pain worse at night
  • Unrelenting pain despite high doses of analgesics
  • History of malignancy
  • History of immunosuppression
  • Recent procedure known to cause bacteremia

5
Physical Exam
  • Always perform a detailed physical exam, keeping
    in mind that back pain may result from multiple
    organ systems.
  • Dont forget to look at vital signs
  • - hypotension? AAA
  • - hypertension ? aortic dissection
  • - fever ? epidural abscess, vertebral
    osteomyelitis
  • The neurologic exam is critical! Thoroughly
    assess
  • - motor function
  • - sensation
  • - deep tendon reflexes
  • - gait
  • - rectal tone
  • - postvoid residual in patients who describe
    urinary retention.

6
Physical Exam
  • As with the history, there are important Physical
    exam RED FLAGS that should not be overlooked
  • Fever
  • Hypotension
  • Extreme hypertension
  • Pale, ashen appearance
  • Pulsatile abdominal mass
  • Pulse amplitude differentials
  • Spinous process tenderness
  • Focal neurologic signs
  • Acute urinary retention

7
Work up
  • If Aortic dissection is suspected
  • Emergent imaging required.
  • CXR is only 64 sensitivity and 86 sensitive.
  • Therefore, CT or MRI are needed (CT usually used
    because it is fast).
  • If AAA suspected
  • If patient has hypotension, pain, and pulsatile
    mass CALL SURGERY, check stat labs (including
    type and cross), place central access.
  • If the patient is clinically stable, an urgent CT
    should be obtained to determine size of AAA and
    to rule out rupture.
  • -

8
Work Up
  • If epidural abscess is suspected
  • Obtain cbc diff, ESR, CRP, blood cultures ( in
    about 60 of these patients).
  • LP NOT recommended.
  • MRI is imaging method of choice because it
    delineates extent of abscess (essential for
    planning surgery), and can differentiate
    infection from cancer.
  • There is a high false negative rate with CT.

MRI scan demonstrating an anterior epidural
abscess.
9
Work Up
  • If vertebral osteomyelitis is suspected
  • Check CBC diff, ESR, CRP, blood cultures ( in
    50-70 of patients).
  • Gadolinium-enhanced MRI is the imaging modality
    of choice.
  • If MRI not possible, CT can be used however
    early destructive changes may be missed. CT
    findings may also be nondiagnostic.

MR image demonstrating cervical vertebral
osteomyelitis at C3-4 epidural abscess is also
present.
10
Work Up
  • If cord compression suspected
  • THIS IS A SURGICAL EMERGENCYcontact
    neurosurgical service immediately.
  • MR imaging and myelography are superior to plain
    radiographs, bone scans, and CT for diagnosis.
  • Myelography is often faster, but is invasive and
    has several contraindications (ie coagulopathy).

T2-weighted MRI with soft tissue mass involving
C7, T1, and T2, with collapse of the vertebrae
and cord compression.
11
Work Up
  • If new diagnosis of malignancy is suspected
    (without evidence of cord compression)
  • Consider these cancers prostate, breast, lung,
    renal cell, non-Hodgkin's lymphoma, and
    plasmacytoma or multiple myeloma (they are the
    most likely to cause lesions in vertebra).
  • Check ESR, CBC, calcium, PSA, SPEP/UPEP
    (depending on suspicion for particular
    malignancies).
  • Plain films have poor sensitivity (60 for
    cancer) but may be chosen as initial imaging
    modality given low cost.
  • MRI is the best imaging modality to determine
    diagnosis.

12
In Summary
  • Although back pain is extremely common and
    usually self-limited, always think about the
    potentially life threatening conditions that it
    may represent.
  • A detailed history and physical are vital.
  • Dont hesitate to call a surgical consultation
    before obtaining imaging (ie if cord compression
    is suspected).
  • Think about the best imaging procedure for the
    diagnosis being considered obtaining unnecessary
    imaging can be a waste precious time.

13
References
  • A. Praemer, S. Furner and D. Rice,
    Musculoskeletal conditions in the United States,
    Proceedings of the American Academy of Orthopedic
    Surgeons, AAOS, Rosemont (IL) (1992), pp. 2333.
  • L.G. Hart, R.A. Deyo and D.C. Cherkin, Physician
    office visits for low back pain frequency,
    clinical evaluation, and treatment patterns from
    a US national survey, Spine 20 (1995), pp. 1119.
  • . Deyo, J. Rainville and D. Kent, What can the
    history and physical examination tell us about
    low back pain, JAMA 286 (1992), pp. 760765.
  • C.B. Higgins, Modern imaging of the acute aortic
    syndrome, Am J Med 116 (2004), p. 134.
  • J.G. Jarvik and R.A. Deyo, Diagnostic evaluation
    of low back pain with emphasis on imaging, Ann
    Intern Med 137 (2002), pp. 586597.
  • Sartoris DJ, André M, Resnik CS, Resnick D,
    Resnick C. Trabecular bone density in the
    proximal femur quantitative CT assessment. Work
    in progress. Radiology. 1986160707-12.
  • Danner RL, Hartman BJ. Update of spinal epidural
    abscess 35 cases and review of the literature.
    Rev Infect Dis 19879265-274. 
  • Curry WT Jr, Hoh BL, Amin-Hanjani S, Eskandar EN.
    Spinal epidural abscess clinical presentation,
    management, and outcome. Surg Neurol
    200563364-371. 
  • Daroiuche RO. Spinal epidural abscess. N Engl J
    Med. 2006 Nov 9355(19)2012-20.
  • Seldomridge JA. Spinal infections diagnostic
    tests and imaging studies SO Clin Orthop Relat
    Res. 2006 Mar44427-33.
  • Posner, JB. Neurologic Complications of Cancer.
    FA Davis, Philadelphia, 1995.
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