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Case Presentation

Case Presentation. Dave Choi PGY-4 Emergency Medicine Edmonton. Learning Goals. Present an interesting case Briefly review relevant material Be done in 25 minutes… really. The Case. Day shift at the Foothills Just finished resusitating a level 1 trauma patient

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Case Presentation

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

  2. Learning Goals • 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”

  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

  5. History • Noticed lower back pain at night initially • No history of trauma • Constant pain • Mildly relieved by hot compresses, and pain medications • Activity doesn’t 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

  7. History • 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

  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.

  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?

  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

  12. MSK Exam • No erythema/warmth/swelling over back • Pain is midline but not worse with palpation • No atrophy legs • Normal SLR tests (Lasegue’s) • Normal ROM lower back (Schober’s) • 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

  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

  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, Paget’s • Visceral disease (~2%) • Disease of pelvic organs, renal disease, AAA, GI

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

  17. 10 days later… • Patient sent into ER from GP’s 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

  19. 10 days later… • 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

  21. It’s 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

  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

  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

  25. Case continued • Working Dx = Urinary retention 2o 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

  27. Investigations • 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

  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

  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 Hoffman’s, 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?

  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

  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

  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

  35. Investigation / Treatment 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

  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

  38. ?

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

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