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Low Back Pain Brad Bunney, MD Department of Emergency Medicine University of Illinois College of Medicine-Chicago Chicago, IL.

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Presentation on theme: "Low Back Pain Brad Bunney, MD Department of Emergency Medicine University of Illinois College of Medicine-Chicago Chicago, IL."— Presentation transcript:

1 Low Back Pain Brad Bunney, MD Department of Emergency Medicine University of Illinois College of Medicine-Chicago Chicago, IL

2 Brad Bunney, MD 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 Brad Bunney, MD 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 Brad Bunney, MD 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 Brad Bunney, MD 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 Brad Bunney, MD Epidemiology 60-90% experience back pain in lifetime 60-90% experience back pain in lifetime 5 million disabled 5 million disabled No definitive diagnoses in 80% No definitive diagnoses in 80% 90% get better no matter therapy 90% get better no matter therapy

7 Brad Bunney, MD Anatomy Vertebra – body, neural arch, bony process Vertebra – body, neural arch, bony process Ligaments & muscles = stability Ligaments & muscles = stability Cervical nerve roots pass above body Cervical nerve roots pass above body All others pass below All others pass below

8 Brad Bunney, MD Types of Back Pain Local Local Referred Referred Radicular Radicular

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

10 Brad Bunney, MD Types of Back Pain Referred Non-spinal referred to back Non-spinal referred to back - Abdominal aortic aneurysm Originate in spine but felt elsewhere Originate in spine but felt elsewhere - Upper lumbar pain felt in upper thighs Rarely extends below the knee Rarely extends below the knee

11 Brad Bunney, MD Types of Back Pain Radicular Irritation of the nerve root Irritation of the nerve root Can radiate to the calf and feet Can radiate to the calf and feet Worse with movement that increases CSF pressure Worse with movement that increases CSF pressure

12 Brad Bunney, MD Nerve Root Diagnosis L4 Pain = lateral back, antero-lateral thigh, anterior calf Pain = lateral back, antero-lateral thigh, anterior calf Numbness = anterior thigh Numbness = anterior thigh Weakness = quadriceps Weakness = quadriceps Diminished knee jerk Diminished knee jerk Squat and rise Squat and rise

13 Brad Bunney, MD Nerve Root Diagnosis L5 Pain = hip, groin, postero-lateral thigh, lateral calf and dorsum of foot Pain = hip, groin, postero-lateral thigh, lateral calf and dorsum of foot Numbness = lateral calf Numbness = lateral calf Weakness = dorsiflex great toe Weakness = dorsiflex great toe Heel walking Heel walking

14 Brad Bunney, MD Nerve Root Diagnosis S1 Pain = mid-gluteal region, posterior thigh, posterior calf to heel & sole Pain = mid-gluteal region, posterior thigh, posterior calf to heel & sole Numbness = posterior calf Numbness = posterior calf Weakness = plantar flex great toe Weakness = plantar flex great toe Diminished ankle jerk Diminished ankle jerk Walk on toes Walk on toes

15 Brad Bunney, MD Spinal Cord Compression Malignant epidural spinal cord compression (MESCC) Malignant epidural spinal cord compression (MESCC) Disc herniation Disc herniation Spinal epidural abscess (SEA) Spinal epidural abscess (SEA) Spinal epidural hematoma (SEH) Spinal epidural hematoma (SEH)

16 Brad Bunney, MD Spinal Cord Compression Factors Force of compression Force of compression Direction of compression Direction of compression Rate of compression Rate of compression

17 Brad Bunney, MD MESCC Hematogenous spread Hematogenous spread Bone marrow Bone marrow Compress cord and vascular supply Compress cord and vascular supply Edema, infarction Edema, infarction

18 Brad Bunney, MD MESCC Prostate Prostate Lung Lung Breast Breast Non-Hodgkin’s lymphoma Non-Hodgkin’s lymphoma Multiple myeloma Multiple myeloma Renal cell cancer Renal cell cancer

19 Brad Bunney, MD MESCC Initial presentation in 20% of malignancies Initial presentation in 20% of malignancies Cervical, thoracic & lumbar by proportion of vertebral body volume Cervical, thoracic & lumbar by proportion of vertebral body volume Thoracic is most common Thoracic is most common

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

21 Brad Bunney, MD MESCC 75% have weakness by time of diagnosis 75% have weakness by time of diagnosis Weakness symmetric Weakness symmetric Ascending numbness Ascending numbness Autonomic dysfunction, urinary retention Autonomic dysfunction, urinary retention

22 Brad Bunney, MD MESCC Plain X-ray 10-17% false negative Plain X-ray 10-17% false negative 30-50% of bone must be destroyed for X-ray to be positive 30-50% of bone must be destroyed for X-ray to be positive MRI, CT myelography are standards MRI, CT myelography are standards

23 Brad Bunney, MD MESCC Corticosteroids first line for edema Corticosteroids first line for edema Dexamethosone, mg load, mg 4 times/day Dexamethosone, mg load, mg 4 times/day Radiation therapy within 24 hours Radiation therapy within 24 hours

24 Brad Bunney, MD MESCC Surgery for: Surgery for: -unresponsive to radiation therapy -Acute neurological deteriorations Chemotherapy – Non-Hodgkin’s lymphoma Chemotherapy – Non-Hodgkin’s lymphoma

25 Brad Bunney, MD Disc Herniation L4-5, L5-S1 most common L4-5, L5-S1 most common Cervical and thoracic do occur Cervical and thoracic do occur Thoracic: abrupt neuro deficits Thoracic: abrupt neuro deficits -Narrow canal Postero-lateral aspect of the disc Postero-lateral aspect of the disc

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

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

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

29 Brad Bunney, MD Disc Herniation Absolute indication for surgery Absolute indication for surgery -Significant muscle weakness -Progressive neurological deficit with bed rest -Bowel or bladder dysfunction

30 Brad Bunney, MD Disc Herniation Relative indication for surgery Relative indication for surgery -Pain despite bed rest -Recurrent episodes of severe pain

31 Brad Bunney, MD SEA Risk Factor IVDA IVDA Diabetes Diabetes Trauma Trauma Prior spinal surgery or nerve blocks Prior spinal surgery or nerve blocks Immune compromised host Immune compromised host

32 Brad Bunney, MD SEA Presenting Complaints Back pain Back pain Paresthesias Paresthesias Motor deficits Motor deficits Fever Fever

33 Brad Bunney, MD SEA Diagnosis WBC WBC Sedimentation Rate Sedimentation Rate MRI = gold standard MRI = gold standard

34 Brad Bunney, MD SEA Organisms Staphylococcus aureus Staphylococcus aureus - Methicillin resistant – 15% Streptococcus Streptococcus Escherichia coli Escherichia coli Pseudomonas Pseudomonas Klebsiella Klebsiella Mycobacterium Tuberculosis Mycobacterium Tuberculosis

35 Brad Bunney, MD SEA Treatment Surgery – depending on Surgery – depending on -severity of neuro deficits -Extent of spine involved -Infecting organism Antibiotics Antibiotics

36 Brad Bunney, MD SEA Non-Operative Indications Panspinal involvement Panspinal involvement Lumbosacral SEA and normal neuro exam Lumbosacral SEA and normal neuro exam Fixed neuro deficit for > 48 hours Fixed neuro deficit for > 48 hours

37 Brad Bunney, MD SEA Antibiotics Start immediately Start immediately Vancomycin Vancomycin Aminoglycoside or 3 rd generation cephalosporin Aminoglycoside or 3 rd generation cephalosporin 4 to 6 weeks 4 to 6 weeks

38 Brad Bunney, MD Spinal Epidural Hematoma (SEH) Risk Factors Coagulapathy Coagulapathy Trauma Trauma Vascular lesion Vascular lesion Surgery Surgery Epidural catheterization Epidural catheterization

39 Brad Bunney, MD SEH Diagnosis Back pain, neuro deficit Back pain, neuro deficit Symptom onset to max. neuro deficit = 13 hours Symptom onset to max. neuro deficit = 13 hours All segments of spinal cord All segments of spinal cord MRI = gold standard MRI = gold standard Plain X-ray or CT scan for fractures or dislocation Plain X-ray or CT scan for fractures or dislocation

40 Brad Bunney, MD SEH Treatment Surgical evacuation Surgical evacuation Immediate surgery within 12 hours of presentation had better outcome than later surgery Immediate surgery within 12 hours of presentation had better outcome than later surgery

41 Brad Bunney, MD 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 Brad Bunney, MD Conclusion Back pain is common in the ED Back pain is common in the ED Radicular pain requires diligence to find the cause Radicular pain requires diligence to find the cause The severity of spinal cord compression is related to force, duration and rate The severity of spinal cord compression is related to force, duration and rate Emergent therapy is necessary Emergent therapy is necessary “Spinal Cord Attack” “Spinal Cord Attack”

43 Brad Bunney, MD First line of therapy for epidural spinal cord compression from metastatic cancer is: A.Radiation therapy B.Surgery C.Corticosteroids D.Chemotherapy

44 Brad Bunney, MD 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 Brad Bunney, MD 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 Brad Bunney, MD 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 Brad Bunney, MD 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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