Upload
lewis-garrett
View
220
Download
1
Tags:
Embed Size (px)
Citation preview
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 symptom-free 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!