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

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 2 2 2

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 3 3 3

7. Anatomy Vertebra – body, neural arch, bony process
Ligaments & muscles = stability
Cervical nerve roots pass above body
All others pass below 3 3 3

8. Local Referred Radicular
Types of Back Pain
Local
Referred
Radicular 3 3 3

9. Types of Back Pain Local
Irritation of bone, muscle, joints
Steady, sharp or dull
Worse with movement 3 3 3

10. Types of Back Pain Referred
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 3 3 3

11. Types of Back Pain Radicular
Irritation of the nerve root
Can radiate to the calf and feet
Worse with movement that increases CSF pressure 3 3 3

12. Pain = lateral back, antero-lateral thigh, anterior calf
Nerve Root Diagnosis L4
Pain = lateral back, antero-lateral thigh, anterior calf
Numbness = anterior thigh
Weakness = quadriceps
Diminished knee jerk
Squat and rise 3 3 3

13. Numbness = lateral calf Weakness = dorsiflex great toe Heel walking
Nerve Root Diagnosis L5
Pain = hip, groin, postero-lateral thigh, lateral calf and dorsum of foot
Numbness = lateral calf
Weakness = dorsiflex great toe
Heel walking 3 3 3

14. Numbness = posterior calf Weakness = plantar flex great toe
Nerve Root Diagnosis S1
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 3 3 3

15. Spinal Cord Compression
Malignant epidural spinal cord compression (MESCC)
Disc herniation
Spinal epidural abscess (SEA)
Spinal epidural hematoma (SEH) 3 3 3

16. Spinal Cord Compression Factors
Force of compression
Direction of compression
Rate of compression 3 3 3

17. Compress cord and vascular supply Edema, infarction
MESCC
Hematogenous spread
Bone marrow
Compress cord and vascular supply
Edema, infarction 3 3 3

18. Non-Hodgkin’s lymphoma Multiple myeloma Renal cell cancer
MESCC
Prostate
Lung
Breast
Non-Hodgkin’s lymphoma
Multiple myeloma
Renal cell cancer 3 3 3

19. Initial presentation in 20% of malignancies
MESCC
Initial presentation in 20% of malignancies
Cervical, thoracic & lumbar by proportion of vertebral body volume
Thoracic is most common 3 3 3

20. Precedes other symptoms by 1-2 months
MESCC
95% have back pain
Precedes other symptoms by 1-2 months
Percussion tendencies, thoracic location, worse lying down 3 3 3

21. 75% have weakness by time of diagnosis
MESCC
75% have weakness by time of diagnosis
Weakness symmetric
Ascending numbness
Autonomic dysfunction, urinary retention 3 3 3

22. Plain X-ray 10-17% false negative
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 3 3 3

23. Corticosteroids first line for edema
MESCC
Corticosteroids first line for edema
Dexamethosone, mg load, 4-24 mg 4 times/day
Radiation therapy within 24 hours 3 3 3

24. Chemotherapy – Non-Hodgkin’s lymphoma
MESCC
Surgery for:
unresponsive to radiation therapy
Acute neurological deteriorations
Chemotherapy – Non-Hodgkin’s lymphoma 3 3 3

25. Cervical and thoracic do occur Thoracic: abrupt neuro deficits
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 3 3 3

26. Not necessary to have history of strain or injury
Disc Herniation
Not necessary to have history of strain or injury
Unilateral radicular back pain with nerve root impingement 3 3 3

27. X-ray only good if inter-vertebral disc is narrow
Disc Herniation
X-ray only good if inter-vertebral disc is narrow
MRI is gold standard
Electromyelography localizes the specific nerve root 3 3 3

28. Initial therapy is to decrease pressure on the root
Disc Herniation
Initial therapy is to decrease pressure on the root
Bed rest up to 4 weeks
Non-steroid anti-inflammatory
Muscle relaxants 3 3 3

29. Absolute indication for surgery
Disc Herniation
Absolute indication for surgery
Significant muscle weakness
Progressive neurological deficit with bed rest
Bowel or bladder dysfunction 3 3 3

30. Relative indication for surgery
Disc Herniation
Relative indication for surgery
Pain despite bed rest
Recurrent episodes of severe pain 3 3 3

31. Prior spinal surgery or nerve blocks Immune compromised host
SEA Risk Factor
IVDA
Diabetes
Trauma
Prior spinal surgery or nerve blocks
Immune compromised host 3 3 3

32. SEA Presenting Complaints
Back pain
Paresthesias
Motor deficits
Fever 3 3 3

33. WBC Sedimentation Rate MRI = gold standard
SEA Diagnosis
WBC
Sedimentation Rate
MRI = gold standard 3 3 3

34. SEA Organisms Staphylococcus aureus Streptococcus Escherichia coli
- Methicillin resistant – 15%
Streptococcus
Escherichia coli
Pseudomonas
Klebsiella
Mycobacterium Tuberculosis 3 3 3

35. SEA Treatment Surgery – depending on Antibiotics
severity of neuro deficits
Extent of spine involved
Infecting organism
Antibiotics 3 3 3

36. SEA Non-Operative Indications
Panspinal involvement
Lumbosacral SEA and normal neuro exam
Fixed neuro deficit for > 48 hours 3 3 3

37. Aminoglycoside or 3rd generation cephalosporin
SEA Antibiotics
Start immediately
Vancomycin
Aminoglycoside or 3rd generation cephalosporin
4 to 6 weeks 3 3 3

38. Spinal Epidural Hematoma (SEH) Risk Factors
Coagulapathy
Trauma
Vascular lesion
Surgery
Epidural catheterization 3 3 3

39. SEH Diagnosis 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 3 3 3

40. SEH Treatment Surgical evacuation
Immediate surgery within 12 hours of presentation had better outcome than later surgery 3 3 3

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” 3 3 3

43. A. Radiation therapy B. Surgery C. Corticosteroids D. Chemotherapy
First line of therapy for epidural spinal cord compression from metastatic cancer is:
A. Radiation therapy
B. Surgery
C. Corticosteroids
D. Chemotherapy 10 6 8

44. A. 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 spine
B. Thoracic spine
C. Lumbar spine
D. Sacral spine 10 6 8

45. A. Pan-spinal involvement
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 10 6 8

46. B. 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 compression
B. Length of spinal cord compressed
C. Duration of compression
D. Rate of compression 10 6 8

47. The most common organism cultured in spinal epidural abscesses is:
A. Streptococcus
B. Pseudomonas
C. Staphylococcus aureus
D. Klebsiella
E. Mycobacterium tuberculosis 10 6 8