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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

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HIGH RISK BACK PAIN: MORE THAN JUST MOTRIN!

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  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

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