The Challenge of Acute Back The Challenge of Acute Back PainPain

Emergency Department, WanFang HospitEmergency Department, WanFang Hospitalal

Ping Hsun, LeePing Hsun, Lee

IntroductionIntroduction

Back pain is one of the most common symptoms that brings patients to the ED

Elderly patient with back pain and osteophyte Young athlete with pain caused by back traum

a

Cannot miss diagnoses0.7% - spinal malignancy0.01% - spinal infections

The Diagnostic The Diagnostic ImperativeImperative

Correctly diagnose- Minimizing expensive diagnostic testing

1. Is there likely to be a serious systemic disease causing the pain?

2. Does the patient have a neurologic disease requiring neuro-surgical evaluation?

3. Is there psychological stress that might be excerbating the patient's condition?

The Diagnostic The Diagnostic ImperativeImperative

1. Those patients with serious spinal conditions.

2. Those patients with sciatica, suggesting nerve root compression.

3. Those patients with non-specific symptoms who fit into neither of the above categories.

Patient SatisfactionPatient Satisfaction

Providing a likely diagnosis A discussion of maneuvers that will restore

functional status A brief explanation A plan directed at pain management

Anatomic and Physiological Anatomic and Physiological ConsiderationsConsiderations

Clinical anatomy is essential for diagnostic purposes

Anteriorly - vertebral bodies Laterally - pedicles and transverse process Posterior - laminae and spinous processes The spinal cord itself ends at the L1-L2 interspa

ce

Anatomic and Physiological Anatomic and Physiological ConsiderationsConsiderations

Intervertebral disks are a common site for back pain-related pathology

The pressure within the disks increases with cough, straining, bending, and sitting

These disks often begin to degenerate at about 30 y/o

Most often posterolaterally

Anatomic and Physiological Anatomic and Physiological ConsiderationsConsiderations

The epidural space lies between the vertebral periosteum and the dura that envelops the - Fat- Connective tissue- Extensive venous plexus

Requires about a 50% reduction in the A-P diameter of the spinal canal to produce neurological symptoms

Differential DiagnosisDifferential Diagnosis

Spinal causesCentral disk herniationTumorInfection: vertebral osteomyelitis, epidural abscess, brucellosis, TuberculosisEpidural hematomaTransverse myelitisAnkylosing spondylitisSpinal stenosis

Differential DiagnosisDifferential Diagnosis

Abdominal causesBilliary disease: cholecystitis, pancreatitisGI: posterior penetrating ulcer, esophageal diseaseGYN disease: ovarian torsion, mass, abscess

Retroperitoneal causesVascular: AAA, dissection, RPHRenal: stone, tumor, abscess, obstructionPancreatic: abscess, pancreatitis, mass

Differential DiagnosisDifferential Diagnosis Pulmonary causes

Any process inflaming the posterior parietal pleura: tumor, infarction, infection, pleurisy

Systemic causesEndocarditis and bacteremiaTransfusion reactions

Clinical ApproachClinical Approach Sudden onset of acute back pain in an

older patient History of cancer Elder patient with hypertension History of a known aortic aneurysm History of peptic ulcer disease Medication history Recent back surgery

Clinical ApproachClinical Approach History taking

- Onset of pain- Duration- Character- Factors that exacerbate or ameliorate the pain- Trauma history- Fever or chills- Back that worse at night or with rest- Radiation of pain

Clinical ApproachClinical Approach

Abdomen- Unilateral distribution- Bilateral

Social history

Physical ExaminationPhysical Examination

Careful and meticulous neurological examination of the lower extremities

The back should be inspected for ecchymosis and deformity

Range of motion Straight leg raise test

Physical ExaminationPhysical Examination

About 95-98% of all lumbar disk herniations involve the L5 and S1 roots

The majority of other herniations affect the L3 and L4 roots (the femoral nerve)

Physical ExaminationPhysical Examination L3-L4 lesion - decreased strength of knee extension

- decreased sensation of the medial knee- a compromised knee reflex

L5 lesion - impaired extension of the great toe - decreased sensation of the first dorsal web space - no reflex changes

S1 lesion - weakened plantar flexion of the foot - decreased sensation in the lateral aspect

of the fifth toe - decreased or absent ankle jerk

Physical ExaminationPhysical Examination Rectal examination is usually useful and essential

in- those with extreme pain- whose history suggests sphincter abnormalities- those with any abnormality found by neurological examination- those at risk for serious, “cannot-miss” diagnoses

Urinary retention (90%)

Diminished anal sphincter tone (70%)

Assessing the ability of the patient with back pain to ambulate

Laboratory and Laboratory and Radiographic StudiesRadiographic Studies

Presence of neurological abnormalities Known malignant disease HIV infection or other immunocompromise Elderly patient with progressive systemic sym

ptoms

Laboratory and Laboratory and Radiographic StudiesRadiographic Studies

Urinalysis Complete blood count Erythrocyte sedimentation rate Calcium Alkaline phosphatase levels

Laboratory and Laboratory and Radiographic StudiesRadiographic Studies

Plain films Radionuclide scans CT scans MR scans Myelography Bone scans

Risk Stratification for Risk Stratification for ImagingImaging

Duration > 4 weeks Failure of conservative therapy or increasing s

ymptoms during conservative therapy Bilateral radicular symptoms Focal lower extremity weakness (recent use of walki

ng aid, frequent falls) History of malignancy (or suspicion of recent non-intens

ional weight loss) HIV infection with CD4 counts of < 200

Risk Stratification for Risk Stratification for ImagingImaging

Urinary urgency or loss of sphincter control Fever (without alternative source), recent infections Claudication (neurogenic or vascular) Drug history

immunosuppressive drugs or chronic steroidsIVDAanticoagulation with INR > 3.0

Recent back surgery or spinal anesthesia and on anticoagulants

Risk Stratification for Risk Stratification for ImagingImaging

Fever (without alternative source) Abdominal mass or tenderness Abnormal neurological findings

- cord lesion- cauda equina lesion- nerve plexus lesion- nerve root (radicular) lesion

Simple and Mechanical Simple and Mechanical CauseCause

The most non-traumatic low back pain are musculoskeletal origin

Only a few percent of which are sciatica Benign natural history

Simple and Mechanical Simple and Mechanical CauseCause

Highly selective imaging in patients with back pain

The clinician should explain that based on a careful history and physical examination, that there is nothing to suggest a serious cause of the back pain

The physician should explain that plain X-rays frequently do not show the relevant structures that may be causing back pain

That MR scanning, while it will show those details, is so snesitive that it often shows potentially misleading abnormalities

Simple and Mechanical Simple and Mechanical CauseCause

Traditionally, bed rest has been the cornerstone of therapy for simple, mechanical low back pain or a herniated disk without neuromotor signs

Continuation of normal activities as tolerated had a more rapid recovery

Strenuous activities or heavy lifting, even if “normal” for an individual patient, should be limited

Prolong sitting may cause increased discomfort If bed reat is prescribed, it should be only for a sh

ort period

Simple and Mechanical Simple and Mechanical CauseCause

Acetaminophen Aspirin Other NSAIDs COX-2 inhibitor

Muscle relaxants Injections of facet joints and trigger points Physical manipulation Epidural injections

Simple and Mechanical Simple and Mechanical CauseCause

Despite documented success with conservative therapy, the occasional patient with a herniated disk will require surgery- Sciatica is both severe and disabling- Symptoms of sciatica persist without improvement or show progression- Clinical evidence of nerve compromise

““Cannot Miss” Cannot Miss” ConditionsConditions

Non-spinal causes- aortic dissection- expansion or rupture of an abdominal aortic aneurysm- abdominal disease

Disk herniation- the vast majority of herniated disk rupture posterolaterally- fewer than 1% displace directly posteriorly (or centrally)

Disk HerniationDisk Herniation Cauda equina syndrome

- back and bilateral leg pain, numbness- sphincter dysfunction

Urinary retention (90%) Anal sphincter dysfunction (70%) Anesthesia of the perineum (saddle anesthesi

a) and of the posteromedial thigh (75%) Patient who rapidly develop neurologic dysfun

ction must be decompressed surgically

Ankylosing SpondylitisAnkylosing Spondylitis Young male Slowly progressive back ache and stiffness Worse in the morning and improves over the

course of the day Gradually, these patients develop

diminished ROM of the back PE reveals diminished excursion of the

lumbar spine and chest Plain film ESR

Abdominal Aortic Abdominal Aortic AneurysmAneurysm

Older, hypertensive patients Back pain, high blood pressure, and a pulsatile ab

dominal mass Shock

Differential diagnosis- Osteoarthritic back pain- Renal colic- Acute diverticulitis- GI bleeding

Abdominal Aortic Abdominal Aortic AneurysmAneurysm

The abdominal examination is highly unreliable for diagnosing an AAA

Abdominal bruit An AAA generally can be palpated above the

umbilicus and to the right of the midline When palpation of the aorta reveals lateral

displacement of the pulse wave, AAA should be suspected

Diminished lower extremity pulses Peripheral emboli or arterial occlusive disease

Abdominal Aortic Abdominal Aortic AneurysmAneurysm

> 80% of patients who present with ruptured aneurysms have never been diagnosed as having an AAA

Abdominal, flank, or back pain are the most common symptoms in patients with a rapidly expanding or ruptured AAA

Syncope A pulsatile abdominal mass

Abdominal Aortic Abdominal Aortic AneurysmAneurysm

Ultrasonography- 100% sensitive- noninvasive- relatively inexpensive- distinguish free intraperitoneal blood

- aneurysmal rupture- complications evluation- thoracic or suprarenal aorta

Abdominal Aortic Abdominal Aortic AneurysmAneurysm

CT scan- able to measure the size- show the full anatomic involvement- aortic lumen size- presence of mural thrombus- hematoma (from rupture)

- dissection- retroperitoneal structures

Abdominal Aortic Abdominal Aortic AneurysmAneurysm

Patient in whom AAA is strongly suspected must be managed in a rapid, directed manner

To stabilize and monitor the patient’s hemodynamic status

Surgical and radiological consultation Unstable patients should be taken directly to t

he operation room

Infections of the Spine and Infections of the Spine and Spinal CanalSpinal Canal

Vertebral Osteomyelitis Epidural abscess Intra-medullary abscess

Early diagnosis and definitive therapy

Vertebral OsteomyelitisVertebral Osteomyelitis The vertebral bodies have a rich, but sluggish

blood supply One artery supplies two vertebrae along with t

he interventing disk Vertebral osteomyelitis of the spine typically i

nvolve two adjacent vertebral bodies Tumor infiltration may involve only a single ve

rtebral body Vertebral osteomyelitis can develop from hem

atogenous or contiguous spread of infection

Vertebral OsteomyelitisVertebral Osteomyelitis Back pain Fever (50%) Radicular pain, including hip pain Dysphagia, pleural effusions Spinal tenderness Diminished ROM Positive straight leg raising test

Vertebral OsteomyelitisVertebral Osteomyelitis Because this process usually involves the anterior

vertebral body, the back pain can percede onset of neurologic findings by some time

Pyogenic vertebral osteomyelitis of the posterior elements has been reported but is far less common

Staphylococcus aureus is the most common offending organismGram-negative enteric speciesSalmonella Tuberculosis, brucellosis

Vertebral OsteomyelitisVertebral Osteomyelitis Bacterial cases

- lumbar (50%)

- thoracic (35%)

- cervical (15%) Tuberculous cases are much more common in

the thoracic spine Plain films are abnormal in as many as 95% of

cases MR scanning

Epidural AbscessEpidural Abscess Vertebral osteomyelitis Genitourinary infections Soft-tissue infections Epidural anesthesia Back surgery Trauma Diabetes IVDA Alcoholism

Epidural AbscessEpidural Abscess

Back pain Radicular pain Motor, sensory, sphincter symptoms Back (or neck) stiffness Fever (75%) Spinal tenderness Normal neurological examination (approximately 5

0%)

Epidural AbscessEpidural Abscess

WBC > 11000 (less than 70%) ESR Positive blood culture (60%) Staphylococcus aureus is by far the most common

organismStreptococcal and gram-negative enteric organism

Cervical location is not uncommon Usually extends over multiple vertebral segments

(> 4) Plain X-ray are positive in 44 - 65% of cases

Epidural AbscessEpidural Abscess

Intravenous antibiotics Surgical decompression Early neurosurgical consultation is important Patient outcome are largely a function of the ne

urologic condition at the time of presentation and duration of neurological deficits prior to examination

Mortality rate: 5 - 23%

Spinal CancerSpinal Cancer

Metastatic disease in the spine Lung cancer

Breast cancerProstate cancerLymphomaRenal cell carcinomaMelanomaSarcomaMultiple myelomaThyroid cancer

Spinal CancerSpinal Cancer

Among cases of metastatic bone involvement, the spine is the most commonly involved site

The vertebral body is usually involved first Direct epidural extension (85%) Radiographic evidence of vertebral metastatic

disease can be a late event

Spinal CancerSpinal Cancer

Thoracic location is most common (60 - 70%)

Prostate and colon cancer tend to spread to the lumbar area

Lung cancer preferentially affect the thoracic spine

Breast and prostate cancer tend to spread multiple areas

The rate of development of compression

Spinal CancerSpinal Cancer

Pain (back pain to radicular pain to neurological signs) The pain produced by spinal metastatic diseas

e is similar to herniated disk SLR test Cancer pain can occur at any area in the spine Pain from cancer tends to be unaffected or wo

rse with rest or at night Delayed diagnosis

Spinal CancerSpinal Cancer

For patient with neurological findings, MR scanning is clearly indicated, the only issue being how urgent

Knowledge of the primary tumor Proceeding to MR scanning directly as the best poli

cy 25% of cancer patients whose symptoms or signs s

uggest radiculopathy, and who have normal plain films, have metastatic epidural cord compression

Conventional CT scan or myelography

Spinal CancerSpinal Cancer

Patients with signs of cord or cauda equina lesion should be imaged within hours

Those with root or plexus lesions and with isolated back pain can be imaged urgently, preferably within 24 hours

Consultation with the patient’s oncologist, as well as with a radiation oncologist and neurosurgeon

Steroids and radiation therapy Decompressive surgery

Spinal HematomasSpinal Hematomas Rare but serious disease Peak incidence between 50 and 80 years of age Posterolateral in location Rupture of veins in the spinal epidural plexus

Anticoagulation Recent spinal surgery Spinal anesthesia Lumbar puncture

Back Pain in the ElderlyBack Pain in the Elderly

Patients older than the age of 50 years have a higher incidence of “cannon miss” diagnoses

Herniated disk is less common Age older than 70 as a risk factor for spinal fractur

e Spinal stenosis

- central canal diameter less than 11mm- lateral recesses depth less than 3mm- hypertrophic soft tissue- bony degenerative change

Spinal StenosisSpinal Stenosis Neurogenic claudication (60 - 100%)

- pain in the legs- with or without neurologic symptoms (especially paresthesias)

- occur with walking, exercise in the erect posture, even standing

Indication for surgery- increasing symptoms- incapacitation

OsteoarthritisOsteoarthritis

The clinician must always consider osteoarthritis in the differential diagnosis of elderly patients presenting to the ED

Osteoarthritis is the most commonly diagnosed joint disorder in the elderly population

Radiographic criteria- joint space narrowing- bony sclerosis- cyst formation- osteophyte formation

OsteoarthritisOsteoarthritis

Primary and secondary Final common pathway More prevalent symptomatically in female Secondary osteoarthritis

- mechanical- congenital- development disorder- systemic disease

OsteoarthritisOsteoarthritis Historical support and radiographic confirmation of o

steophytes Joint pain Pain with use and relief with rest The pain is usually aching and will progress to chronic

pain Insidious and usually takes months to years to develo

p Monoarticular in its early presentation Involvement of the wrist, shoulder, or elbow is uncom

mon

OsteoarthritisOsteoarthritis

Pain management Functional improvement Acetaminophen

NSAIDs (Ibuprofen, Napoxen)COX-2 inhibitor (Celecoxib, Rofecoxib)

Neuro-Imaging of Back Pain PatieNeuro-Imaging of Back Pain Patientsnts

Low RiskLow Risk Patients with none of the high-risk criteria No imaging studies needs Patient education

- Thorough explanation of medical decision making prognosis with realistic time course (3-6 weeks) explanation of why imaging studies are not indicated

Treatment- non-narcotic analgesia- consider physical therapy, heat, cold, other- early return to routine activities- delayed exercise of back, abdomen

Follow-Up- With PCP if not improving as expected

Neuro-Imaging of Back Pain PatieNeuro-Imaging of Back Pain Patientsnts

Medium RiskMedium Risk Risk factors plus normal exam

Risk factors plus exam showing root or plexus lesion

MRI done urgently (< 24 hours) MRI negative

- careful follow-up by PCP

- consultation as appropriate MRI positive

- treatment and consultation appropriate for diagnosis

Neuro-Imaging of Back Pain PatieNeuro-Imaging of Back Pain Patientsnts

High RiskHigh Risk Exam shows cord or cauda equina lesion

Fever and suspicion of epidural abscess or hematomaAbdominal exam suggest AAAUrinary urgency or sphincter symptoms

MRI done emergently (within several hours) MRI (or other imaging study) negative

- consultation to determine etiology of symptoms and signs MRI (or other imaging study) positive

- treatment and consultation appropriate for diagnosis

Summary and Diagnostic Summary and Diagnostic AlgorithmAlgorithm

To identify the vast majority of back pain patients with serious disease

Simultaneously avoiding unnecessary imaging studies

Whatever algorithm is chosen, the emergency physician must remain alert for patients whose back pain falls into the

“cannot miss” group

Thank Thank You!You!