Transcript Back Pain
Back Pain Introduction • Definitions • History with red flags • Physical Examination with red flags • Diagnostic testing • Treatment • Sciatica and Back Pain • Epidural Compression Syndrome • Vertebral Osteomyelitis • Back Pain in the Cancer Patient Definitions • Low back pain: pain located between the lower rib cage and the gluteal folds – Extending or radiating into the thighs • Acute: lasting less than six weeks • Subacute: lasting between 6 and 12 weeks • Chronic: lasting longer than 12 weeks History Is Key! Red Flags • Less than 18 yrs of age • More than 50 yrs of age • Trauma (even minor if patient is elderly or taking steroids chronically) • Cancer • Fever, chills, night sweats • Weight loss Red Flags • • • • • • Injection drug use Compromised immunity Recent GI or GU procedure Pain at night Pain radiating below knee Pain with prolonged sitting, coughing, or Valsalva manouver Red Flags • Severe and unremitting pain • Incontinence, saddle anesthesia • Severe or rapidly progressing neurologic deficit Age • More than 50 years old or younger than 18 • Older than 50 – Tumor – Abdominal aortic aneurysm – Infection Age • Older than 65 – Hypertrophic degenerative spinal stenosis • Under 18 – Congenital defect – Tumor – Infection – Spondylolysis – Spondylolisthesis Duration of Pain • Approximately 80% of patients with acute low back pain will be symptomfree within six weeks • Pain lasting longer: tumor, infection, or a rheumatologic etiology Location and Radiation of the Pain • Muscular or ligamentous strain or disk disease without nerve involvement – Primarily in the back with radiation into the buttocks or thighs • Radiating below the knee, especially calf and foot – Nerve root inflammation below L3 level • Approximately 95% of all herniated disks occur at the level of either L4-L5 or L5-S1 Location and Radiation of the Pain History of Trauma • Major or minor trauma – Elderly or chronic steroid user: Fracture! • More likely to have osteoporosis • Fall from a standing or a seated position Systemic Complaints • Constitutional symptoms – Fever, night sweats, malaise, or unintended weight loss – Infection or malignancy • More worrisome for infection if additional risk factors – Recent bacterial infection – Immunocompromised status Systemic Complaints • Injection drug user: assumed to be osteomyelitis or epidural abscess until these conditions are ruled out by diagnostic studies • Recent invasive procedures, such as colonoscopy Atypical Pain • Typical pain: dull, achy pain that is exacerbated with movement and improves with rest • Tumor and infection – – – – Worse at night Often awakens patient from sleep Not relieved with rest Unrelenting despite appropriate analgesic treatment Atypical Pain • Worsened with prolonged sitting, coughing, and the Valsalva maneuver: Disk Herniation Associated Neurological Symptoms • Epidural compression syndrome (spinal cord compression, cauda equina syndrome, or conus medullaris syndrome) – Saddle anesthesia – Bowel or bladder incontinence – Erectile dysfunction – Severe and progressive neurologic deficit Associated Neurological Symptoms • Residual bladder volumes – Assist in the evaluation of bladder incontinence – Large post-void residual volumes: significant neurologic compromise. Evaluate for epidural compression syndrome Associated Neurological Symptoms • Complaints of worsening paresthesias, weakness, gait disturbances – Single nerve root pathology: compression by a herniated disk – Multiple or bilateral nerve root complaints: compression from a mass History of Cancer • Risk of metastatic spread to the spine • Most likely to metastasize to the spine: – Breast, lung, thyroid, kidney, prostate cancer • Primary tumors originating in the spine: – osteosarcoma, lymphoma, multiple myeloma, neurofibromas Physical Examination is Vital! Physical Examination • Vital signs – Fever: red flag for infection • • • • 27% of patients with tuberculous osteomyelitis 50% of patients with pyogenic osteomyelitis 87% of patients with spinal epidural abscess Absence of fever does not rule out spinal infection Physical Examination • General appearance – Benign low back pain: patients prefer to remain still – Writhing in pain or in extreme pain • Spinal infection • Abdominal aortic aneurysm • Nephrolithiasis Physical Examination • Expose back and palpate – History of trauma: focus on midline spinous processes for tenderness – Muscular spasm or edema Physical Examination • Lower extremity strength and sensation – Focus on muscle groups and dermatomes innervated by specific spinal nerve roots – Patellar and Achilles reflexes: symmetry – Babinski's test: upper motor nerve syndrome – All deficits or abnormalities should be compared with the nerve root involved Straight Leg Raising • Evaluate for disk herniation • Patient placed in the supine position. Leg elevated by clinician up to 70 degrees • Positive test: radicular pain below the knee along the path of a nerve root in the 30- to 70- degree range of elevation • Further verified by lowering the leg 10 degrees from the point of radicular pain and dorsiflexing the foot Straight Leg Raising Straight Leg Raising • Reproduction of back pain or pain in the hamstring is not a positive test! • 80% sensitive for disk herniation • Positive crossed straight leg raise: radicular pain down the affected leg when the asymptomatic leg is raised – Highly specific but not sensitive Rectal Examination • Integral part of examination of patients with back pain • Perianal sensation, rectal tone, and rectal and prostatic masses – Abnormal tone or sensation: bulbocavernous reflex testing and anal wink • Poor rectal tone in association with back pain and saddle anesthesia: epidural compression syndrome Diagnostic Testing Laboratory Tests • Infection or tumor: – CBC: elevated WBC count consistent with infection – ESR: elevated in infection and rheumatologic disease. Also marker of an undiscovered malignancy – CRP: same as the ESR – UA: UTI in patients who have evidence of spinal infection. Urinary system common primary source for such infections Radiography • Plain radiographs: simply not necessary in the absence of red flags • Concern for fracture, infection, rheumatologic disease, or metastatic disease – Anteroposterior and lateral films • Magnetic resonance imagery (MRI) or computed tomography (CT) if films negative and concern remains Radiography • MRI – Gold standard for compressive lesion of the spinal cord or cauda equina, spinal infection, or disk herniation. – May be delayed for four to six weeks if disk herniation is the only concern Radiography • CT – Study of choice for bony structure • Spinal trauma: spinal column stability and integrity of spinal canal • Vertebral osteomyelitis – CT-myelogram in absence of MRI: epidural compressive lesions Treatment of Benign Acute Low Back Pain Activity • No benefit of prolonged bed rest 1 • Recently shown that patients who resumed their normal activities to whatever extent they could tolerate recovered faster than those who stayed in bed for two days • Active exercise: not beneficial during acute stage • After recovery, exercise helps prevent future episodes 1. How many days of bed rest for acute low back pain? A randomized clinical trial. N Engl J Med 1986; 315:1064-70 Analgesia • Mainstays of pharmacologic therapy: acetaminophen, NSAIDs, and opiate analgesics • Acetaminophen: analgesic with proven efficacy comparable to NSAIDs – Inexpensive – Innocuous side-effect profile Analgesia • NSAIDs: equally efficacious in the management of acute pain – Best to choose lowest effective dose based on side effects and cost • Opiate analgesics: moderate to severe pain – Combinations of acetaminophen and codeine phosphate, hydrocodone, or oxycodone • Other medications – muscle relaxants, such as diazepam, methocarbamol, and cyclobenzaprine Sciatica and Back Pain Sciatica • Sciatica: pain radiating along a nerve root path to the foot – Afflicts 2% to 3% of patients with low back pain • Compression of a nerve root by a herniated nucleus pulposus • Associated weakness, paresthesias, and numbness along a nerve root Sciatica Sciatica • More than 95% of disk herniations occur at the L4-L5 or L5-S1 levels, corresponding to L5 or S1 radiculopathies • Other causes of nerve root irritation: – Space-occupying lesions (including central canal or foraminal stenosis, usually found in patients over age 50) – Tumor – Hematoma – Infection Sciatica Sciatica • Outcome generally positive: – 50% recovering in six weeks – 5% to 10% ultimately require surgery • Management similar to uncomplicated low back pain – – – – Limited bed rest Activity as tolerated Analgesics Steroids: epidural steroid injection produces mild to moderate reduction in pain Sciatica • Radiographs not required – Only to rule out bony pathology – MRI: needed emergently only if patient has a progressing neurologic deficit Epidural Compression Syndrome Epidural Compression Syndrome • Encompasses: – Spinal cord compression – Cauda equina syndrome – Conus medullaris syndrome • Grouped together because: – Similar presentation except for the level of the neurologic deficit – Similar evaluation and management until actual diagnosis is known Epidural Compression Syndrome • Medical Emergency! • Difficult to evaluate patients with early signs and symptoms – Broad initial differential diagnosis – Determine whether symptoms are bilateral – Evaluate combination of motor, sensory, and autonomic dysfunction Epidural Compression Syndrome • Signs and symptoms: – Minimal low back complaints – Constipation or incontinence of the bowel – Urinary retention or incontinence – Saddle anesthesia – Decreased rectal tone Epidural Compression Syndrome • Possible etiologies – Large central disk herniation – Spinal canal hematoma – Spinal canal abscess – Primary or metastatic tumor – Traumatic compression Epidural Compression Syndrome • Emergent treatment with spinal cord injury assumption: – Dexamethasone 10 to 100 mg IV administered immediately • Emergent MRI – Cervical, thoracic, and lumbosacral spine if concern about possible metastatic compression or infection Epidural Compression Syndrome • Outcomes dependent on presenting neurologic deficits – Paraplegic on presentation - unlikely to walk again – Too weak to walk without assistance, but not paraplegic - 50% chance of walking again – Ambulatory at presentation - remained so – Catheterized for a denervated bladder – most will not recover bladder function Vertebral Osteomyelitis Vertebral Osteomyelitis • Often missed on routine examination • History very helpful in making diagnosis – – – – – 90% have back pain as primary symptom Severe pain, commonly nocturnal and unremitting Only 52% febrile at presentation Only 10% appear septic or toxic Injection drug use: assumed to be osteomyelitis or epidural abscess until proven otherwise – Recent UTI, pneumonia, GI or GU procedure Vertebral Osteomyelitis • Transplant patients and other immunocompromised patients: increased risk for septicemia and osteomyelitis • Organisms: – Staphylococcus aureus most common – Escherichia coli, Proteus, and Pseudomonas • Hematogenous spread with deposit in the vertebral matrix around the sluggish venous plexuses Vertebral Osteomyelitis • Evaluation – – – – – WBC count may be elevated ESR almost always elevated Urinalysis Blood cultures positive in more than 40% Plain radiographs: may be normal • Bony destruction, moth-eaten end plates, and narrowing of disk spaces – MRI: gold-standard • Brightening of the marrow on T2, brightening of the disk on T2, and darkening of the marrow on T1 Vertebral Osteomyelitis Vertebral Osteomyelitis • Cornerstone of treatment: IV antibiotics – Six to eight weeks IV antistaphylococcal – Followed by oral antibiotics for another four to eight weeks – Analgesics and bed rest – Immobilization with an orthosis – Surgery reserved for: • • • • Significant abscesses Spinal cord compression Significant bony destruction Unresponsive to standard medical treatment Back Pain in the Cancer Patient The Cancer Patient • Difficult to evaluate: – Spinal metastases – Devastating consequences if significant lesion is missed • Separate patients into three groups based on symptoms The Cancer Patient • First group – Signs and symptoms of progressive epidural compression – True medical emergency – High-dose steroids and emergent MRI The Cancer Patient • Second group – Mild, stable symptoms – Isolated nerve root involvement – Do not require high-dose steroids or emergent MRI The Cancer Patient • Third group – – – – – Majority of patients Isolated pain with no neurologic deficits Plain radiographs: MRI if metastases detected Followed closely for two to three weeks Remember: • 50% bone destruction must occur before radiographs can detect a lytic lesion • 60% of patients with metastatic disease will have normal radiographs Summary • • • • History: Keep red flags in mind Physical Exam: red flags again SLR and Sciatica Treatment for benign low back pain is analgesics • Epidural compression syndrome is a medical emergency • Appropriate imaging. Plain films usually not needed References • • • • www.emedicine.com www.mdchoice.com www.webmd.com Emergency Medicine – Judith E. Tintinalli. 6th Edition • Rosen’s Emergency Medicine – 5th Edition Thank You!