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Case Presentation Dave Choi PGY-4 Emergency Medicine Edmonton Dave Choi PGY-4 Emergency Medicine Edmonton.

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Presentation on theme: "Case Presentation Dave Choi PGY-4 Emergency Medicine Edmonton Dave Choi PGY-4 Emergency Medicine Edmonton."— Presentation transcript:

1 Case Presentation Dave Choi PGY-4 Emergency Medicine Edmonton Dave Choi PGY-4 Emergency Medicine Edmonton

2 Learning Goals Present an interesting case Briefly review relevant material Be done in 25 minutes… really. Present an interesting case Briefly review relevant material Be done in 25 minutes… really.

3 The Case Day shift at the Foothills Just finished resusitating a level 1 trauma patient Feeling good about your intubation and chest tube skills, you move to the minor side to see a patient with low back pain Day shift at the Foothills Just finished resusitating a level 1 trauma patient Feeling good about your intubation and chest tube skills, you move to the minor side to see a patient with low back pain

4 History Mr G. 58 y.o. male Walked into ER c/o lower back pain x 1/12 Seen by GP last week given toradol and percocet, also put on Flomax for BPH Mr G. 58 y.o. male Walked into ER c/o lower back pain x 1/12 Seen by GP last week given toradol and percocet, also put on Flomax for BPH

5 History Noticed lower back pain at night initially No history of trauma Constant pain Mildly relieved by hot compresses, and pain medications Activity doesnt make it better or worse Wakes him up at night sometimes Noticed lower back pain at night initially No history of trauma Constant pain Mildly relieved by hot compresses, and pain medications Activity doesnt make it better or worse Wakes him up at night sometimes

6 History Pain has been getting bit worse Worse with coughing, straining Radiating to flank/groin x 1/52 Some voiding difficulty (hard start) x 1/52 No bowel incontinence Pain has been getting bit worse Worse with coughing, straining Radiating to flank/groin x 1/52 Some voiding difficulty (hard start) x 1/52 No bowel incontinence

7 History No fever, chills, night sweats ~5lb weight loss over last couple months No fever, chills, night sweats ~5lb weight loss over last couple months

8 Red Flags Pain not relieved by lying down Night pain Leg weakness Bowel, bladder, sexual symptoms Fever (esp. IVDU) Weight loss Pain not relieved by lying down Night pain Leg weakness Bowel, bladder, sexual symptoms Fever (esp. IVDU) Weight loss

9 History PmHx: cholesterol Meds: Crestor 10mg PO QD, Percocet 1tab PO Q4H prn, Toradol 10mg PO Q6H prn Allergies: NKDA FHx: father MI at 80 y.o. PmHx: cholesterol Meds: Crestor 10mg PO QD, Percocet 1tab PO Q4H prn, Toradol 10mg PO Q6H prn Allergies: NKDA FHx: father MI at 80 y.o.

10 History SHx -non smoker -occas. EtOH -no illegal drugs -worked as senior manager for Telus, retired earlier this year, exercises 3x/week, going on holidays soon ANY OTHER QUESTIONS? Ddx? SHx -non smoker -occas. EtOH -no illegal drugs -worked as senior manager for Telus, retired earlier this year, exercises 3x/week, going on holidays soon ANY OTHER QUESTIONS? Ddx?

11 O/E Vitals: T36.8, P54, RR15, BP137/83, Sat 99% Heart S1S2, no EHS/murmurs/rubs Lungs clear, AE=AE Abd soft, normal BS, bit tender suprapubic, no peritoneal signs/guarding No pulsating mass, no flank tenderness Vitals: T36.8, P54, RR15, BP137/83, Sat 99% Heart S1S2, no EHS/murmurs/rubs Lungs clear, AE=AE Abd soft, normal BS, bit tender suprapubic, no peritoneal signs/guarding No pulsating mass, no flank tenderness

12 MSK Exam No erythema/warmth/swelling over back Pain is midline but not worse with palpation No atrophy legs Normal SLR tests (Lasegues) Normal ROM lower back (Schobers) Normal gait No erythema/warmth/swelling over back Pain is midline but not worse with palpation No atrophy legs Normal SLR tests (Lasegues) Normal ROM lower back (Schobers) Normal gait

13 Neuro Exam Motor: 5/5 power UE, Slight decreased power L hip flexor, otherwise normal Sensation: normal UE/LE, no saddle anesthesia, normal rectal tone, mild prostate enlargement DTR +2 bilat UE, +1 bilat LE, no Babinski Motor: 5/5 power UE, Slight decreased power L hip flexor, otherwise normal Sensation: normal UE/LE, no saddle anesthesia, normal rectal tone, mild prostate enlargement DTR +2 bilat UE, +1 bilat LE, no Babinski

14 Investigations Xray Lspine - mild degen changes Hgb158 WBC5.9 Plt 243 Na140 K4.1 Cl105 bicarb27 Cr100, Urea5.5 Urine neg leuks/protein/hgb Bladder scanned for 154ml Xray Lspine - mild degen changes Hgb158 WBC5.9 Plt 243 Na140 K4.1 Cl105 bicarb27 Cr100, Urea5.5 Urine neg leuks/protein/hgb Bladder scanned for 154ml

15 Differential Dx Low Back Pain Mechanical (>95%) -Lumbar strain (70%), degenerative process (10%), herniated disk (4%), spinal stenosis (3%), OP compression # (4%), spondylolisthesis (2%), traumatic # (<1%), congenital disease (<1%), disc disruption Non-mechanical spinal conditions (~1%) -Neoplasia, infection, inflammatory arthritis, Pagets Visceral disease (~2%) -Disease of pelvic organs, renal disease, AAA, GI Mechanical (>95%) -Lumbar strain (70%), degenerative process (10%), herniated disk (4%), spinal stenosis (3%), OP compression # (4%), spondylolisthesis (2%), traumatic # (<1%), congenital disease (<1%), disc disruption Non-mechanical spinal conditions (~1%) -Neoplasia, infection, inflammatory arthritis, Pagets Visceral disease (~2%) -Disease of pelvic organs, renal disease, AAA, GI

16 PLAN D/C home? Any other investigations? -FAST (aorta) Follow up? D/C home? Any other investigations? -FAST (aorta) Follow up?

17 10 days later… Patient sent into ER from GPs office for in/out cath and urinalysis Lower abdominal discomfort Cannot sleep Patient sent into ER from GPs office for in/out cath and urinalysis Lower abdominal discomfort Cannot sleep

18 Physical Exam Chest clear Abd: bit distended, dull to percussion, suprapubic discomfort to palpation, symmetric fullness Neuro exam unchanged from previous Bladder scanned for 550ml, foley drained 500ml, foley left in Chest clear Abd: bit distended, dull to percussion, suprapubic discomfort to palpation, symmetric fullness Neuro exam unchanged from previous Bladder scanned for 550ml, foley drained 500ml, foley left in

19 10 days later… Urinalysis: 3+ leuks, many bacteria Started on Septra Discharged home with U/S pelvis booked for next day Urinalysis: 3+ leuks, many bacteria Started on Septra Discharged home with U/S pelvis booked for next day

20 PLAN Leave catheter in Toradol 30mg IM Buscopan 10mg PO Patient feels bit better U/S pelvis tomorrow Leave catheter in Toradol 30mg IM Buscopan 10mg PO Patient feels bit better U/S pelvis tomorrow

21 Its tomorrow U/S abdo/pelvis – normal GB + bile ducts, liver grossly normal, pancreas, spleen, aorta normal, multiple bilateral renal cysts, but kidneys otherwise normal Now what? Dx = prostate hyperplasia, UTI, and mechanical back pain U/S abdo/pelvis – normal GB + bile ducts, liver grossly normal, pancreas, spleen, aorta normal, multiple bilateral renal cysts, but kidneys otherwise normal Now what? Dx = prostate hyperplasia, UTI, and mechanical back pain

22 Case continued Urology consult for cystoscopy as outpatient

23 28 days later Still c/o back pain worse at night Very tender suprapubic area Numbness / tingling feet started 1 week ago Meds: Flomax, Proscar, Flexeril, Percocet prn, Toradol prn Still c/o back pain worse at night Very tender suprapubic area Numbness / tingling feet started 1 week ago Meds: Flomax, Proscar, Flexeril, Percocet prn, Toradol prn

24 28 days later O/E: AVSS Neuro Exam -Motor: 4+/5 hip flexors, others 5/5 -Sensation: numb over plantar feet bilat, touch/pinprick ok -DTR +1 LE bilat, +2 UE bilat, no Babinski -No saddle anesthesia -Rectal tone intact O/E: AVSS Neuro Exam -Motor: 4+/5 hip flexors, others 5/5 -Sensation: numb over plantar feet bilat, touch/pinprick ok -DTR +1 LE bilat, +2 UE bilat, no Babinski -No saddle anesthesia -Rectal tone intact

25 Case continued Working Dx = Urinary retention 2 o to BPH and LBP (mechanical)

26 Hmm… Pt returns to ED 3 more times in the next 4 days c/o urinary retention and suprapubic discomfort Now c/o bilateral numbness/tingling feet and lower back pain radiating to bilateral thighs Pt returns to ED 3 more times in the next 4 days c/o urinary retention and suprapubic discomfort Now c/o bilateral numbness/tingling feet and lower back pain radiating to bilateral thighs

27 Investigations Pt booked for outpt MRI L-spine for ?neurogenic claudication by GP Cystoscopy – mildly enlarged prostate Pt booked for outpt MRI L-spine for ?neurogenic claudication by GP Cystoscopy – mildly enlarged prostate

28 2 weeks later… Returns to ED c/o gradual bilateral leg weakness L>R Has been unable to walk independently over last 4 days (using walker) Foley catheter in situ x 3 weeks Unable to cope at home Returns to ED c/o gradual bilateral leg weakness L>R Has been unable to walk independently over last 4 days (using walker) Foley catheter in situ x 3 weeks Unable to cope at home

29 Recap of the Events LBP, gradual onset and worsening, night pain, worse with valsalva x 4/12 Pain radiating to bilat thighs and groin x 3/12 Numbness/tingling bilat feet, ascending from feet to thigh x 1/12 Urinary retention x 1/12, indwelling foley x 3/52 Gradual bilateral leg weakness x 2/52 LBP, gradual onset and worsening, night pain, worse with valsalva x 4/12 Pain radiating to bilat thighs and groin x 3/12 Numbness/tingling bilat feet, ascending from feet to thigh x 1/12 Urinary retention x 1/12, indwelling foley x 3/52 Gradual bilateral leg weakness x 2/52

30 Neuro Exam Now Motor: UE normal; 3/5 Hip flexors, 3+/5 Quads, 4/5 Hamstrings, 4/5 ankle dorsi/plantarflexion Sensation: saddle anesthesia! Reflexes: no DTRs LE, no Hoffmans, no Babinski, normal bulbocavernosus reflex and rectal tone Motor: UE normal; 3/5 Hip flexors, 3+/5 Quads, 4/5 Hamstrings, 4/5 ankle dorsi/plantarflexion Sensation: saddle anesthesia! Reflexes: no DTRs LE, no Hoffmans, no Babinski, normal bulbocavernosus reflex and rectal tone

31 Case continued Admitted under neurosurgery MRI – syrinx vs inflammatory or neoplastic cord disease, suggest LP by neurology to r/o viral etiology Lumbar Puncture – WBC103 RBC96 Prot4.15 (<0.45) Glu2.6 (2.2-4.4) neg cultures Diagnosis? Admitted under neurosurgery MRI – syrinx vs inflammatory or neoplastic cord disease, suggest LP by neurology to r/o viral etiology Lumbar Puncture – WBC103 RBC96 Prot4.15 (<0.45) Glu2.6 (2.2-4.4) neg cultures Diagnosis?

32 Case CT chest/abd – no aortic dissection MRA – suspicious for dural AV fistula arising from upper lumbar region causing ischemia OR – L2-4 laminectomy and clipping of spinal dural AV fistula CT chest/abd – no aortic dissection MRA – suspicious for dural AV fistula arising from upper lumbar region causing ischemia OR – L2-4 laminectomy and clipping of spinal dural AV fistula

33 Dural AV fistula a.k.a. Foix-Alajouanine Syndrome AV malformation of spinal cord vessels, usually lower thoracic or lumbosacral Can lead to ischemic injury of the cord Male:Female 4:1 Usually >50yo Symptoms gradual onset over months to years a.k.a. Foix-Alajouanine Syndrome AV malformation of spinal cord vessels, usually lower thoracic or lumbosacral Can lead to ischemic injury of the cord Male:Female 4:1 Usually >50yo Symptoms gradual onset over months to years

34 Symptoms / Signs -Weakness / numbness / tingling of LE -Gradual onset + worsening LE weakness -Urinary / fecal incontinence -lower back pain +/- radiating -Abnormal gait -Spastic or flaccid paraparesis +/- sensory level -DTR variable; +/- Babinski -Decreased rectal tone -Weakness / numbness / tingling of LE -Gradual onset + worsening LE weakness -Urinary / fecal incontinence -lower back pain +/- radiating -Abnormal gait -Spastic or flaccid paraparesis +/- sensory level -DTR variable; +/- Babinski -Decreased rectal tone

35 Investigation / Treatment INVESTIGATION MRI Myelogram angiography TREATMENT Embolization of AVM Laminectomy w/ obliteration of AV shunt INVESTIGATION MRI Myelogram angiography TREATMENT Embolization of AVM Laminectomy w/ obliteration of AV shunt

36 Case Electrodiagnostic Study -Axonal injury to leg muscles L>R -Considerable # motor neurons still intact, prognosis for functional recovery reasonably good Electrodiagnostic Study -Axonal injury to leg muscles L>R -Considerable # motor neurons still intact, prognosis for functional recovery reasonably good

37 Mr. G now Back pain significantly reduced Unable to ambulate Self in/out catheterizations BMs ok Still hoping to go on planned holidays to Hawaii in the future Back pain significantly reduced Unable to ambulate Self in/out catheterizations BMs ok Still hoping to go on planned holidays to Hawaii in the future

38 ?

39 Summary Red flags for Low back pain Multiple ER visits with same problem, do not get blinded by the diagnosis Red flags for Low back pain Multiple ER visits with same problem, do not get blinded by the diagnosis


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