1 / 68

HIGH RISK BACK PAIN: MORE THAN JUST MOTRIN!

HIGH RISK BACK PAIN: MORE THAN JUST MOTRIN!. Nilesh Patel February 19, 2009 St. Joseph’s Regional Medical Center Paterson NJ. OBJECTIVES. Epidemiology Differential Red Flags High Risk Presentations Pearls & Pitfalls. EPIDEMIOLOGY. Very common chief complain in ED

eilis
Download Presentation

HIGH RISK BACK PAIN: MORE THAN JUST MOTRIN!

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. HIGH RISK BACK PAIN: MORE THAN JUST MOTRIN! Nilesh Patel February 19, 2009 St. Joseph’s Regional Medical Center Paterson NJ

  2. OBJECTIVES • Epidemiology • Differential • Red Flags • High Risk Presentations • Pearls & Pitfalls

  3. EPIDEMIOLOGY • Very common chief complain in ED • >90% benign >> will resolve in 4-6 weeks • “The majority of patients who present to the ED have a non-specific etiology that has no life or limb threatening concerns” • “70-90% of all individuals will suffer back pain at some point in their lives” • 5-10% serious pathology • “One can develop an indifference to this complaint and potentially overlook serious causes of back pain” • History & Physical key to diagnosis

  4. BACK PAIN EMERGENCIES • Vascular • Aortic Dissection • AAA • Infectious • Osteomyelitis/Diskitis • Spinal epidural abscess • Transverse Myelitis • Spinal Cord Compression Syndromes • Cauda Equina Syndrome—malignancy, herniation • Epidural Hematoma • Trauma • Malignancy

  5. BACK PAIN EMERGENCIES • Pulmonary • PE • GI/GU • Retroperitoneal bleed • Ovarian torsion, diverticulitis, appendicitis • Renal • Renal abscess • Renal infarction • Neurologic • Spinal cord infarction

  6. RED FLAGS • Age < 20 or > 60 • Untraditional pain • Constitutional symptoms • Neuro S & S • Hx: • Trauma • Cancer • Immunosuppression • IVDA • Recent instrumentation

  7. PHYSICAL EXAM • Vital signs • Abdomen/GU • Back • Neuro • Motor • Sensory • Reflexes • Gait • Rectal

  8. CASE # 1 • CC: • Back pain • HPI: • 67 y/o male • Left lower lumbar pain • Acute onset • Pain sharp, moderate to severe, non-radiating • Positive SOB

  9. CASE # 1 • PMHx/PSHx: • Severe COPD, HTN • Meds: • Spiriva, Norvasc • Alleriges: • NKDA • SHx: • Former heavy tobacco use. No alcohol or drugs. No IVDA

  10. CASE # 1 • Review of Systems—positive back pain, sob, cough • VS-- 105/58, 120, 20, 96.4, 96% on 3 L • Gen-- AAO, in moderate respiratory distress • CVS-- RRR, tachy, no murmurs • Lungs-- b/l very diminished breath sounds, no W/R/R • Abd-- soft, nontender, normal bowel sounds, no masses • Back-- mild tenderness L flank, no vertebral point tenderness • Neuro-- nonfocal

  11. CASE # 1 • 14.3 Neutrophils 80% 21.4 153 Bands 0 43.0 Cardiac enzymes negative 137 100 20 UA negative 199 EKG sinus tachycardia 4.3 22 1.1

  12. ED COURSE • 11:02 pm…Pt presented to ER via EMS and had initial VS • 105/58 120 20 96.4 96% on 3 L • Pain level 6/10 • 11:18 pm…Pt. evaluated by ER physician • Albuterol 10 mg/Atrovent 1 mg neb, Solumedrol 125 mg IV, Morphine 2 mg IV, NSS 500 cc bolus • 1:00 am… • 108/80 100 20 98% on 2 L • Pain level 5/10 • CT scan a/p without contrast ordered

  13. ED/HOSPITAL COURSE • 1:30 am • 73/52 112 24 97% on 3 L • Vascular surgery urgently consulted • PRBCs ordered • Pt went to OR • 7:30 am…Surgery completed, pt received several units of blood • Pt. expired in SICU shortly after surgery

  14. RUPTURED AAA

  15. EPIDEMIOLOGY • Incidence 36.2 cases/100,000 • Increased incidence with aging • Increased incidence in Caucasians • 5-10% patients age 60-80 will have AAA • 15,000 deaths/year • Very high mortality with rupture

  16. NATURAL HX • Risk of rupture increases with size of aneurysm • Average expansion rate 0.4 cm/year • Aneurysms > 5-6 cm expand more rapidly • Surgical threshold 5-6 cm

  17. PATHOGENESIS • Atherosclerosis…Familial • Infra-renal • Risk Factors • Tobacco use • Age > 60 • HTN • Atherosclerosis • Family Hx • Male gender • COPD

  18. CLINICAL FEATURES • TRIAD • Hypotension • Abdominal Pain/Back pain • Pulsatile abdominal mass

  19. CLINICAL FEATURES • Abdominal pain • Back pain/flank pain • Syncope • Vomiting • SOB • Weakness • Groin pain • VS abnormalities • Pulsatile abdominal mass • Abdominal bruit • Peripheral embolic events • Pulse deficits

  20. DIAGNOSTICS • Clinical • Ultrasound • Sensitivity 95-100% • ED Ultrasound! • CT scan • Sensitivity/Specificity close to 100%

  21. TREATMENT • ED • ABC • IV/O2/Monitor • IVF • PRBCs • Urgent vascular surgery consult • Definitive • Surgery

  22. CASE # 2 • CC: • Back pain • HPI: • 52 y/o male • Lower right sided back pain • Started 5 days ago and worsening • Constant pain, radiates to R hip/groin/abdomen • Worsened by movement • Seen in ER 3 days ago and discharged on pain meds

  23. CASE # 2 • PMHx/PSHx, Meds, Allergies: • None • SHx: • Denied tobacco/alcohol use • Former IV heroin use, quit 8 months ago • ROS positives: • Fever/Chills • Abdominal pain • Back pain • Urinary frequency • Weakness

  24. CASE # 2 • VS-- 102/70 100 20 98.0 100% RA • Gen-- AAO times three, in moderate discomfort • Abd-- soft, mild tenderness rlq, suprapubic area • Back-- tenderness L3-L5, R CVA tenderness, pain with any range of motion • Neuro-- 4/5 motor LE bilaterally (? due to pain); 5/5 motor UE b/l

  25. ED COURSE • Toradol, Percocet • UA—moderate blood (5-9 rbc), no LE or WBC • CT a/p without contrast negative • Upon discharge, pt still with pain • Temp 103.5

  26. CASE # 2 • 14 Neutrophils 80% 23.3 156 Bands 11% 43 ESR 59 135 95 21 CT--? Inflammatory changes 186 anterior to L5-S1 4.2 25 1.7

  27. ED COURSE • Admit • Vancomycin IV • MRI • Osteomyelitis involving L4, L5 • Spinal epidural abscess causing mass effect on cauda equina • Blood Cultures • 2/2 MRSA

  28. SPINAL EPIDURAL ABSCESS

  29. EPIDEMIOLOGY • 0.2-1.2 cases/10,000 hospital admissions • Rare • High morbidity

  30. PATHOGENESIS • Hematogenous spread • Direct Innoculation • Spread from contiguous site • Idiopathic • Staph aureus (MRSA)– 2/3 cases • Staph sp. • Gram negatives (E. coli, Pseudomonas)

  31. RISK FACTORS • Underlying disease • IVDA • Recent instrumentation • Indwelling catheters • Contiguous/hematogenous spread

  32. CLINICAL FEATURES • TRIAD • Back pain • Fever • Neurologic deficit

  33. CLINICAL FEATURES • Journal of EM 2004 • 63 patients • Symptoms • Back pain—95% • Radicular pain—62% • Neuro deficit—41% • Fever—33% • Triad—8%

  34. CLINICAL FEATURES • 98% had at least one risk factor • 68%--multiple ER visits • 75%--diagnostic delay • 45%--neuro deficit due to delay • 62%--concurrent osteomyelitis • 37%--concurrent diskitis • Take Home Points…

  35. DIAGNOSTICS • CBC, ESR,CRP, Blood Cultures • MRI • Diagnostic test of choice • X-ray • CT myelography • Bone Scan • CT scan

  36. TREATMENT • ED • ABCs • IV antibiotics • Urgent neurosurgical consultation • Definitive • IV antibiotics • CT-guided needle aspiration • Surgical drainage

  37. OSTEOMYELITIS/DISKITIS

  38. EPIDEMIOLOGY/PATHOGENESIS • Risk factors similar to SEA • Sickle cell disease • Microbiology • Staph aureus leading cause • Other Staph sp. • Gram negatives • Polymicrobial • TB • Fungal

  39. CLINICAL FEATURES • Acute/subacute/chronic • Back pain • Fever • Systemic symptoms • Cellulitis

  40. DIAGNOSTICS • CBC, ESR, CRP, Blood cultures • X-ray • Bone scan • CT, MRI • Needle biopsy/bone biopsy

  41. TREATMENT • IV antibiotics (prolonged treatment) • Surgical debridement

  42. CASE # 3 • CC: • Weakness • HPI: • 78 y/o male • Weakness over past 1 week, progressively worsening • Weakness pronounce in LE, unable to ambulate • Back pain • Fecal incontinence

More Related