Presentation on theme: "Low Back Pain Brad Bunney, MD Department of Emergency Medicine University of Illinois College of Medicine-Chicago Chicago, IL 1 1 1."— Presentation transcript:
1Low Back Pain Brad Bunney, MD Department of Emergency Medicine University of Illinois College of Medicine-Chicago Chicago, IL111
2Objectives Discuss the different types of back pain Review anatomical principlesReview nontraumatic etiologies for acute back pain with neurological findingsTreatment options for patients with back pain and neurological findings222
3The Case55 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 herniationMeds: noneSochx: alcohol usePE: afebrile, VSSBack: mild tenderness right paraspinal area, L2-3Neuro: normalWhat do you want to do?
4The CaseHe 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, VSSBack: right paraspinal tenderness, worse with movementNeuro: normalWhat do you want to do?
5The CaseHe 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, VSSBack: diffuse tenderness to lumbar spine palpationNeuro: RLE- 3/5 strength, numbness anterior and med thigh, decreased reflex. LLE- 4/5 strength.What do you want to do?
6Epidemiology 60-90% experience back pain in lifetime 5 million disabledNo definitive diagnoses in 80%90% get better no matter therapy333
25Cervical and thoracic do occur Thoracic: abrupt neuro deficits Disc HerniationL4-5, L5-S1 most commonCervical and thoracic do occurThoracic: abrupt neuro deficitsNarrow canalPostero-lateral aspect of the disc333
26Not necessary to have history of strain or injury Disc HerniationNot necessary to have history of strain or injuryUnilateral radicular back pain with nerve root impingement333
27X-ray only good if inter-vertebral disc is narrow Disc HerniationX-ray only good if inter-vertebral disc is narrowMRI is gold standardElectromyelography localizes the specific nerve root333
28Initial therapy is to decrease pressure on the root Disc HerniationInitial therapy is to decrease pressure on the rootBed rest up to 4 weeksNon-steroid anti-inflammatoryMuscle relaxants333
29Absolute indication for surgery Disc HerniationAbsolute indication for surgerySignificant muscle weaknessProgressive neurological deficit with bed restBowel or bladder dysfunction333
30Relative indication for surgery Disc HerniationRelative indication for surgeryPain despite bed restRecurrent episodes of severe pain333
31Prior spinal surgery or nerve blocks Immune compromised host SEA Risk FactorIVDADiabetesTraumaPrior spinal surgery or nerve blocksImmune compromised host333
32SEA Presenting Complaints Back painParesthesiasMotor deficitsFever333
39SEH Diagnosis Back pain, neuro deficit Symptom onset to max. neuro deficit = 13 hoursAll segments of spinal cordMRI = gold standardPlain X-ray or CT scan for fractures or dislocation333
40SEH Treatment Surgical evacuation Immediate surgery within 12 hours of presentation had better outcome than later surgery333
41The CaseMRI 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 mucilaginosisPatient 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.
42Conclusion Back pain is common in the ED Radicular pain requires diligence to find the causeThe severity of spinal cord compression is related to force, duration and rateEmergent therapy is necessary“Spinal Cord Attack”333
43A. Radiation therapy B. Surgery C. Corticosteroids D. Chemotherapy First line of therapy for epidural spinal cord compression from metastatic cancer is:A. Radiation therapyB. SurgeryC. CorticosteroidsD. Chemotherapy1068
44A. Cervical spine B. Thoracic spine C. Lumbar spine D. Sacral spine The most common site of epidural spinal cord compression from metastatic cancer is:A. Cervical spineB. Thoracic spineC. Lumbar spineD. Sacral spine1068
45A. Pan-spinal involvement All of the following are indications for non-operative treatment of spinal epidural abscesses except:A. Pan-spinal involvementB. Lumbosacral SEA and normal neurological examC. Fixed neurological deficits for greater than 48 hrsD. Urinary incontinence and sensory deficit1068
46B. Length of spinal cord compressed C. Duration of compression All of the following contribute to the severity of spinal cord compression except:A. Force of compressionB. Length of spinal cord compressedC. Duration of compressionD. Rate of compression1068
47The most common organism cultured in spinal epidural abscesses is: A. StreptococcusB. PseudomonasC. Staphylococcus aureusD. KlebsiellaE. Mycobacterium tuberculosis1068