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“A disconcertingcause of back
pain”Chidinma Chima-Melton
Critical Care ConferencePulmonary & Critical Care
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Objecties
•!eie" a case of seere lo"back pain in a critical care
setting•Appreciate the importance ofthe history and physical in
assessing lo" back pain•!eie" the emergency causesof lo" back pain# including the
"ork-up and management
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$ho is this%
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$illiam Osler '()*+'*'*,
• Canadian physician and ather of
Modern Medicine• our founding professors of .ohns/opkins /ospital
•
Osler created the 0rst internalmedicine residency program
• Pioneer of bedside teaching for
medical students
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Case PresentationChief Complaint:
1ack painHPI
• 23 year old man "ho presents "ith seerelo"er back pain
• irst noted pain "hen "alking dog ) daysprior to admission
• Came to 45 + gien de6amethasone#
toradol and dilaudid• 7ent home "ith mobic# medrol dose pack
and percocet
• $ent to an outpatient clinic and receied a
steroid hip injection
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Case Presentation cont8d
• Pain did not improe + in fact it got"orse
• $as unable to ambulate due to pain
• Pain "as sharp# in left lo"er back9:ankradiating to groin
• On admission denies any chills# omiting
• !O7; Positie for subjectie feers#diarrhea# "eight loss# nausea and poorPO intake<
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Past Medical /istory
• /=>
• 5egeneratie .oint 5isease
• Psoriatic arthritis
• An6iety and 5epression
• /ypercholesterolemia
• 1enign Prostatic /yperplasia
• ?ocal Cord 5isease
• 7leep Apnea but does not use CPAP
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Medications
• A7P@!@> (' M 4C =A1B4=
• A=O!?A7=A=@> ' M O!AB =A1B4=
• CA!@7OP!O5OB 7OMA,
• @>A7=4!@54 D M O!AB =A1B4=
• M4BOE@CAM 'D M O!AB =A1B4=
• M4=OP!OBOB D M 4E=4>545-!4B4A74 =A1B4=
• OEFCO5O>4
• =4!AGO7@> ' M CAP7HB4
• ?AB7A!=A> '2 M O!AB =A1B4=
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7ocial /istory & amily /6
Social History
• /e "orks as an accountant
• Bies "ith his roommate
• =he patient denies any tobacco use + neersmoker# no alcohol use<
• 5enies any recreational and @? drug use
Family History
• Mother + 5ementia
• ather - 4mphysema
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$hat is the diNerential diagnosis for his
lo" back pain%
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Anatomy of the Bumbar7pine
41 Medicine K'3
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41 Medicine K'3
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Babs on admission
• =roponin '
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Bumbar E-ray obtained
in 45 K days beforeadmission
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M!@ Bumbar spine no gadolinium,in 45 K days before admission
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/ospital Course
• Admitted to the medical :oors
• 7tarted on pain control "ith o6ycodone# dilaudidand muscle rela6ants roba6in
• !eie"ed M!@ lumbar spine
• P= ealuation
• /ome medications continued
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5ay K
• 1ecame hypotensie# febrile# abdomen becamedistended# deeloped bloody diarrhea# nausea#omiting and epigastric pain<
• Bactate eleated 3= output suspicious for coNee ground emesis
•
/e "as transferred to the @CH shortly thereafterfor continuing care<
• QH1 performed this morning demonstrated dilatedloops of bo"el concerning for ileus s 71O# no freeair<
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Babs on @CH transfer
• =roponin @ '
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CE! on =ransfer
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5ay K Continued
• Central line placed and ?asopressors started
• 7urgery consult for concern for 71O + recommend>= to suction decompress,
• 1road spectrum antibiotics ancomycin and
Rosyn @?, initiated• @ consulted for H@1 + PP@ started
• ==4 negatie for ?egetation
• Bo" back pain continued + Pain management
consulted
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Problem Bist 5ay 3 @CH
• 7eptic 7hock reSuiring asopressors
• >odules# consolidations and pleural eNusions onC= Chest
• 71O s ileus
• =hrombocytopenia
• Beukopenia
• AQ@
• >7=4M@
• =ransaminitis• 46cruciating back pain
• A0b "ith !?!
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$/A= @7 =/4 5@4!4>=@AB 5@A>O7@7O! 1ACQ PA@> A= =/@7 =@M4%
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$/A= $O!Q HP $OHB5 FOH
O1=A@> A= =/@7 PO@>=%
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5ay )
• Cultures remained positie for M77A
• HA suggestie of M77A
• $1C scan performed;
'< indings consistent "ith osteomyelitis at =)-=D and
B3-B) as described aboe<K< indings suspicious for in:ammatory9infectiousprocess of the left hip<
3< @nfectious process of the right mid and left lo"erlung<
)< Bikely in:ammatory9infectious process of the colon<
• Cr< @mproed so M!@ "ith ad obtained
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=K "eight thoracic sag
=)-=D osteomyelitis and probable disc space infection "ith anepidural
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=K "eight 7ag Bumbar
5isc space infection B3-) "ith epidural pannus e6tending from B' to BD
"ith moderate central canal stenosis at B3 and B)< @nolement of bothpsoas muscles<
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/ospital Course continued
• Came oN pressors and "as able to leae the @CH
• Beft hip arthrocentesis and :uid gre" M77A
• 45 demonstrating duodenal ulcers and multiplegastric ulcers
• 1lood cultures eentually steriliRed after ' "eek• 1ack pain improed after draining psoas abscess
• 71O improed and diet adanced
• Beukopenia and thrombocytopenia improed
• 7pine consulted conseratie management
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5iagnosis
=)-=D osteomyelitis# B3-B) diskitis and epiduralphlegmon "ith mild cord compression
M77A 1acteremia "ith H=@ and pulmonary
dissemination
B hip M77A 7eptic Arthritis
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Acute Bo" 1ack Pain
• Bo" back pain is the most common type of painreported by adults in the Hnited 7tates
• K2L of the population reporting pain lasting atleast a day in the past 3 months
• 'L of the Hnited 7tates "orkforce considered“permanently disabled” by lumbago<
• @n '**(# direct healthcare costs attributed tolo"er back pain - estimated at T* billion
0 i i
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5e0nitions; Acute Bo"1ack Pain• Acute lo" back pain; 7ymptoms lasting )
"eeks up for 3 months,
• Chronic 1ack pain; Pain syndrome lasting longerthan 3 months<
• 7ciatica; Beg pain that localiRes to lumbar sacral
nere roots*L of pathology occurs at B)-BD andBD-7' leels
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5e0nitions; Acute Bo"1ack Pain• 7pinal stenosis; Cro"ding of the spinal canal#
either by osteoarthritis# osteophytes# ligamentousthickening# and9or bulging interertebral discs
• Myelitis; An in:ammatory condition that aNectsthe spinal cord< often "hite matter anddemyelination are inoled,
•
Cauda eSuina syndrome; Compression of thecauda nere roots,
• 7pondylolisthesis; ?ertebra slips out of position inrelation to the ertebra beneath it<
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4aluation of the lo" back painpatient
Clinicians should conduct a focused history andphysical e6amination to help place patients "ith lo"back pain into ' of 3 broad categories;
'< !ed lag lo" back pain potentially serious,
K< 1ack pain potentially associated "ithradiculopathy or spinal stenosis
3< >onspeci0c back pain most common,
strong recommendation# moderate-Suality
eidence,<
Ann @ntern Med< KIU')II,;)I(-)*'
Ph i l 4 i A
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Physical 46am in AcuteBumbago• @t is fundamental to perform a systematic
neurologic e6amination<
• @nclude pertinent negaties and positiesregarding strength# sensory# re:e6es# gait# rectal
sensation e6amination and assessment for urinaryretention
• =he P4 0ndings or lack of 0ndings, should be thefoundation of the decision to pursue imaging
• More than *L of disc herniations occur at theB)9BD or BD97' leels so a focus on this leel
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$hen to Obtain imaging
• Most lo" back pain self resoles in ) to 2 "eeks soimaging is not recommendedV in patients "ithout red:ags
• A meta-analysis of 2 randomiRed trials of '(patients found no outcome diNerences bet"eenroutine care and no imaging and patients "hounder"ent imaging "ith plain 6-ray# C=# or M!@
• Additionally# M!@ reeals many abnormalities in
asymptomatic patients<
• @n a study of asymptomatic patients aged W 2# 32Lhad a herniated disc# K'L had spinal stenosis# and*L had a degenerated or bulging disc<
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Plain !adiographs
• !outine plain 0lms are not indicated - ery lo" foran interenable lesion or pathology
• @n a study of 2(# radiographs# clinically
unsuspected lesions occurred in ';KD patientsaged K to D years<
• E-ray is recommended in patients "ho hae;
•
5irect trauma-related back pain• 7uspected of haing a possible ertebral
compression fracture
• Foung patients "ith lo"er back pain "hereankylosing spondylitis is suspected
Aft C ti
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After ConseratieManagement• @n patients "ith lo" back pain and radiculopathic
symptoms "ho are still symptomatic after )"eeks of conseratie management and self-care
• @maging should be discussed that can be
interened upon i
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$@=/ =/4 /@/ P!4?AB4>C4 O BHM1AO#$/4> 5O47 @= 14COM4 A> 4M4!4>CF%
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=K-"eighted sagittal M!@ of the spine
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g g psho"ing osteomyelitis at ='K top arro",and partial cord compression at B' bottom
arro",<
AAP
A t B 1 k P i
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Acute Bo" 1ack Pain4mergencies• Cauda 4Suina 7yndrome
• Abdominal Aortic Aneurysm !upture
• 7pinal /ematoma
• 4pidural Abscess
• @n CA74 of 4mergencyX
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Cauda 4Suina 7yndrome•
Cauda eSuina proide motor and sensory functionto the lo"er e6tremities# perineum# and bladder<
• /erniated disks are most common lesions causingcauda eSuina syndrome
•
Other causes are tumors# spinal stenosis#infection# and hematoma
• Presentation; lo" back pain# b9l "eakness in lo"ere6tremities# saddle anesthesia# and abnormalitiesin bladder sensation and function completeersus incomplete syndromes,
• =@P; Measure post oid residual P?!,< P?! 3ml is al"ays abnormal<
• 5iagnosis; M!@ or C= myelogram is needed to
make this diagnosis<
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Abdominal Aortic Aneurysm!upture
• Abdominal aortic diameter 3 cm is aneurysmal'9' patients,
• Abdominal aortic aneurysms are uncommon inpatients aged 2 years<
•
An aneurysm8s siRe correlates "ith risk of rupture•
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7pinal /ematoma• =@P; 7pinal epidural hematomas are rarely
spontaneous< Hsually related to trauma#postoperatie spinal surgery#anticoagulation# thrombolysis# lumbarpuncture# epidural anesthesia#ascular
malformation# or chiropracticmanipulation<
• Presentation; 1ack pain and possible
neurologic complaints• 5iagnosis; A lo" threshold for imaging
"ith M!@ "ith ad or C= myelogram "ithcontrast is needed in suspected patients
• !eerse of coagulopathy# and patients
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4pidural Abscess
• 4pidural abscess is a rare condition
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4pidural AbscessBocations
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4pidural Abscess
• Posterior epidural abscesses tend to be related toa distant focus
• Anterior infections are generally related toosteomyelitis or diskitis "hich can be related to a
distant focus or contiguous spread# such as psoasabscess,
• Presentation; >onspeci0c - can include feer#back pain# and malaise
• 5iagnosis; M!@ "ith gad preferred, or C=
myelogram"ith contrast
• =reatment; )-2 "eeks antibiotics and considersurgical decompression<
i l id l b i
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7pinal 4pidural Abscess - 46perience"ith )2 Patients
• Chart reie" )2 patients 32 men and ' "omen, "ithspinal epidural abscess oer a '-year period
• !isk factors; diabetes )2L,# freSuent enouspuncture 3DL,# spinal trauma K)L,# and history of
spinal surgery KKL,• 47! "as eleated uniformly mean# (2
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$illiam Osler
ZBisten to your patient# for he is telling you thedia nosisZ
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!eferences•
Andersson 1< 4pidemiological features ofchronic lo"-back pain< Bancet<'***U3D)*'I(,;D('-D(D< !eie",
• Chou !# [aseem A# 7no" ?# et al< 5iagnosis andtreatment of lo" back pain; a joint clinicalpractice guideline from the American College ofPhysicians and the American Pain 7ociety< Ann@ntern Med< KIU')II,;)I(-)*'< Clinicalpractice guideline,
• >@C4< >ational @nstitute for /ealth and Clinical46cellence - lo" back pain C((,< K*< Clinicalpractice guideline,
• An 4idence-1ased Approach =o =he 4aluation
And =reatment Of Bo" 1ack Pain @n =he
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