Objectives

1. Low Back PainBrad Bunney, MDDepartment of Emergency MedicineUniversity of Illinois College of Medicine-ChicagoChicago, IL

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

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

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

8. Types of Back Pain Local Referred Radicular

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

10. Types of Back PainReferred 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

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

12. Nerve Root DiagnosisL4 Pain = lateral back, antero-lateral thigh, anterior calf Numbness = anterior thigh Weakness = quadriceps Diminished knee jerk Squat and rise

13. Nerve Root DiagnosisL5 Pain = hip, groin, postero-lateral thigh, lateral calf and dorsum of foot Numbness = lateral calf Weakness = dorsiflex great toe Heel walking

14. Nerve Root DiagnosisS1 • 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

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

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

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

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

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

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

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

22. 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

23. MESCC Corticosteroids first line for edema Dexamethosone, 20-100 mg load, 4-24 mg 4 times/day Radiation therapy within 24 hours

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

25. 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

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

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

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

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

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

31. SEARisk Factor IVDA Diabetes Trauma Prior spinal surgery or nerve blocks Immune compromised host

32. SEAPresenting Complaints Back pain Paresthesias Motor deficits Fever

33. SEADiagnosis WBC Sedimentation Rate MRI = gold standard

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

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

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

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

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

39. SEHDiagnosis 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

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

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”

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

44. 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

45. 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

46. 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

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