Low Back PainLow Back Pain

Brad Bunney, MDBrad Bunney, MD

Department of Emergency MedicineDepartment of Emergency Medicine

University of Illinois College of Medicine-ChicagoUniversity of Illinois College of Medicine-Chicago

Chicago, ILChicago, IL

Brad Bunney, MD

ObjectivesObjectives

• 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

Brad Bunney, MD

The CaseThe 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?

Brad Bunney, MD

The CaseThe 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?

Brad Bunney, MD

The CaseThe 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?

Brad Bunney, MD

EpidemiologyEpidemiology

• 60-90% experience back pain in lifetime60-90% experience back pain in lifetime

• 5 million disabled5 million disabled

• No definitive diagnoses in 80%No definitive diagnoses in 80%

• 90% get better no matter therapy90% get better no matter therapy

Brad Bunney, MD

AnatomyAnatomy

• Vertebra – body, neural arch, bony processVertebra – body, neural arch, bony process

• Ligaments & muscles = stabilityLigaments & muscles = stability

• Cervical nerve roots pass above bodyCervical nerve roots pass above body

• All others pass belowAll others pass below

Brad Bunney, MD

Types of Back PainTypes of Back Pain

• LocalLocal

• ReferredReferred

• RadicularRadicular

Brad Bunney, MD

Types of Back Pain Types of Back Pain LocalLocal

• Irritation of bone, muscle, jointsIrritation of bone, muscle, joints

• Steady, sharp or dullSteady, sharp or dull

• Worse with movementWorse with movement

Brad Bunney, MD

Types of Back PainTypes of Back PainReferredReferred

• Non-spinal referred to back Non-spinal referred to back

- Abdominal aortic aneurysm- Abdominal aortic aneurysm

• Originate in spine but felt elsewhereOriginate in spine but felt elsewhere

- Upper lumbar pain felt in upper thighs- Upper lumbar pain felt in upper thighs

• Rarely extends below the kneeRarely extends below the knee

Brad Bunney, MD

Types of Back PainTypes of Back PainRadicularRadicular

• Irritation of the nerve rootIrritation of the nerve root

• Can radiate to the calf and feetCan radiate to the calf and feet

• Worse with movement that Worse with movement that

increases CSF pressureincreases CSF pressure

Brad Bunney, MD

Nerve Root DiagnosisNerve Root DiagnosisL4L4

• Pain = lateral back, antero-lateral Pain = lateral back, antero-lateral

thigh, anterior calfthigh, anterior calf

• Numbness = anterior thighNumbness = anterior thigh

• Weakness = quadricepsWeakness = quadriceps

• Diminished knee jerkDiminished knee jerk

• Squat and riseSquat and rise

Brad Bunney, MD

Nerve Root DiagnosisNerve Root DiagnosisL5L5

• Pain = hip, groin, postero-lateral Pain = hip, groin, postero-lateral

thigh, lateral calf and dorsum of footthigh, lateral calf and dorsum of foot

• Numbness = lateral calfNumbness = lateral calf

• Weakness = dorsiflex great toeWeakness = dorsiflex great toe

• Heel walkingHeel walking

Brad Bunney, MD

Nerve Root DiagnosisNerve Root DiagnosisS1S1

• Pain = mid-gluteal region, posterior Pain = mid-gluteal region, posterior

thigh, posterior calf to heel & solethigh, posterior calf to heel & sole

• Numbness = posterior calfNumbness = posterior calf

• Weakness = plantar flex great toeWeakness = plantar flex great toe

• Diminished ankle jerkDiminished ankle jerk

• Walk on toesWalk on toes

Brad Bunney, MD

Spinal Cord CompressionSpinal Cord Compression

• Malignant epidural spinal cord Malignant epidural spinal cord

compression (MESCC) compression (MESCC)

• Disc herniationDisc herniation

• Spinal epidural abscess (SEA)Spinal epidural abscess (SEA)

• Spinal epidural hematoma (SEH)Spinal epidural hematoma (SEH)

Brad Bunney, MD

Spinal Cord Compression FactorsSpinal Cord Compression Factors

• Force of compressionForce of compression

• Direction of compressionDirection of compression

• Rate of compressionRate of compression

Brad Bunney, MD

MESCCMESCC

• Hematogenous spreadHematogenous spread

• Bone marrowBone marrow

• Compress cord and vascular supplyCompress cord and vascular supply

• Edema, infarctionEdema, infarction

Brad Bunney, MD

MESCCMESCC

• ProstateProstate

• LungLung

• BreastBreast

• Non-Hodgkin’s lymphomaNon-Hodgkin’s lymphoma

• Multiple myelomaMultiple myeloma

• Renal cell cancerRenal cell cancer

Brad Bunney, MD

MESCCMESCC

• Initial presentation in 20% of Initial presentation in 20% of

malignanciesmalignancies

• Cervical, thoracic & lumbar by Cervical, thoracic & lumbar by

proportion of vertebral body volumeproportion of vertebral body volume

• Thoracic is most commonThoracic is most common

Brad Bunney, MD

MESCCMESCC

• 95% have back pain95% have back pain

• Precedes other symptoms by 1-2 Precedes other symptoms by 1-2

monthsmonths

• Percussion tendencies, thoracic Percussion tendencies, thoracic

location, worse lying downlocation, worse lying down

Brad Bunney, MD

MESCCMESCC

• 75% have weakness by time of 75% have weakness by time of

diagnosisdiagnosis

• Weakness symmetricWeakness symmetric

• Ascending numbnessAscending numbness

• Autonomic dysfunction, urinary Autonomic dysfunction, urinary

retentionretention

Brad Bunney, MD

MESCCMESCC

• Plain X-ray 10-17% false negativePlain X-ray 10-17% false negative

• 30-50% of bone must be destroyed 30-50% of bone must be destroyed

for X-ray to be positivefor X-ray to be positive

• MRI, CT myelography are standardsMRI, CT myelography are standards

Brad Bunney, MD

MESCCMESCC

• Corticosteroids first line for edemaCorticosteroids first line for edema

• Dexamethosone, 20-100 mg load, 4-Dexamethosone, 20-100 mg load, 4-

24 mg 4 times/day24 mg 4 times/day

• Radiation therapy within 24 hoursRadiation therapy within 24 hours

Brad Bunney, MD

MESCCMESCC

• Surgery for:Surgery for:

- unresponsive to radiation therapyunresponsive to radiation therapy

- Acute neurological deteriorationsAcute neurological deteriorations

• Chemotherapy – Non-Hodgkin’s Chemotherapy – Non-Hodgkin’s

lymphomalymphoma

Brad Bunney, MD

Disc HerniationDisc Herniation

• L4-5, L5-S1 most commonL4-5, L5-S1 most common

• Cervical and thoracic do occurCervical and thoracic do occur

• Thoracic: abrupt neuro deficitsThoracic: abrupt neuro deficits

- Narrow canalNarrow canal

• Postero-lateral aspect of the Postero-lateral aspect of the

discdisc

Brad Bunney, MD

Disc HerniationDisc Herniation

• Not necessary to have history of Not necessary to have history of

strain or injurystrain or injury

• Unilateral radicular back pain with Unilateral radicular back pain with

nerve root impingementnerve root impingement

Brad Bunney, MD

Disc HerniationDisc Herniation

• X-ray only good if inter-vertebral X-ray only good if inter-vertebral

disc is narrowdisc is narrow

• MRI is gold standardMRI is gold standard

• Electromyelography localizes the Electromyelography localizes the

specific nerve rootspecific nerve root

Brad Bunney, MD

Disc HerniationDisc Herniation

• Initial therapy is to decrease Initial therapy is to decrease

pressure on the rootpressure on the root

• Bed rest up to 4 weeksBed rest up to 4 weeks

• Non-steroid anti-inflammatoryNon-steroid anti-inflammatory

• Muscle relaxantsMuscle relaxants

Brad Bunney, MD

Disc HerniationDisc Herniation

• Absolute indication for surgeryAbsolute indication for surgery

- Significant muscle weaknessSignificant muscle weakness

- Progressive neurological deficit with Progressive neurological deficit with

bed restbed rest

- Bowel or bladder dysfunctionBowel or bladder dysfunction

Brad Bunney, MD

Disc HerniationDisc Herniation

• Relative indication for surgeryRelative indication for surgery

- Pain despite bed restPain despite bed rest

- Recurrent episodes of severe painRecurrent episodes of severe pain

Brad Bunney, MD

SEASEARisk FactorRisk Factor

• IVDAIVDA

• DiabetesDiabetes

• TraumaTrauma

• Prior spinal surgery or nerve blocksPrior spinal surgery or nerve blocks

• Immune compromised hostImmune compromised host

Brad Bunney, MD

SEASEAPresenting ComplaintsPresenting Complaints

• Back painBack pain

• ParesthesiasParesthesias

• Motor deficitsMotor deficits

• FeverFever

Brad Bunney, MD

SEASEADiagnosisDiagnosis

• WBCWBC

• Sedimentation RateSedimentation Rate

• MRI = gold standardMRI = gold standard

Brad Bunney, MD

SEASEAOrganismsOrganisms

• Staphylococcus aureusStaphylococcus aureus

- Methicillin resistant – 15%- Methicillin resistant – 15%

• StreptococcusStreptococcus

• Escherichia coliEscherichia coli

• PseudomonasPseudomonas

• KlebsiellaKlebsiella

• Mycobacterium TuberculosisMycobacterium Tuberculosis

Brad Bunney, MD

SEASEATreatmentTreatment

• Surgery – depending onSurgery – depending on

- severity of neuro deficitsseverity of neuro deficits

- Extent of spine involvedExtent of spine involved

- Infecting organismInfecting organism

• AntibioticsAntibiotics

Brad Bunney, MD

SEASEANon-Operative IndicationsNon-Operative Indications

• Panspinal involvementPanspinal involvement

• Lumbosacral SEA and normal neuro Lumbosacral SEA and normal neuro

examexam

• Fixed neuro deficit for > 48 hoursFixed neuro deficit for > 48 hours

Brad Bunney, MD

SEASEAAntibioticsAntibiotics

• Start immediatelyStart immediately

• VancomycinVancomycin

• Aminoglycoside or 3Aminoglycoside or 3rdrd generation generation

cephalosporincephalosporin

• 4 to 6 weeks4 to 6 weeks

Brad Bunney, MD

Spinal Epidural Hematoma (SEH)Spinal Epidural Hematoma (SEH)Risk FactorsRisk Factors

• CoagulapathyCoagulapathy

• TraumaTrauma

• Vascular lesionVascular lesion

• SurgerySurgery

• Epidural catheterizationEpidural catheterization

Brad Bunney, MD

SEHSEHDiagnosisDiagnosis

• Back pain, neuro deficitBack pain, neuro deficit

• Symptom onset to max. neuro deficit = 13 Symptom onset to max. neuro deficit = 13

hourshours

• All segments of spinal cordAll segments of spinal cord

• MRI = gold standardMRI = gold standard

• Plain X-ray or CT scan for fractures or Plain X-ray or CT scan for fractures or

dislocationdislocation

Brad Bunney, MD

SEHSEHTreatmentTreatment

• Surgical evacuationSurgical evacuation

• Immediate surgery within 12 hours of Immediate surgery within 12 hours of

presentation had better outcome than presentation had better outcome than

later surgerylater surgery

Brad Bunney, MD

The CaseThe 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.

Brad Bunney, MD

ConclusionConclusion

• Back pain is common in the EDBack pain is common in the ED

• Radicular pain requires diligence to find Radicular pain requires diligence to find

the causethe cause

• The severity of spinal cord compression is The severity of spinal cord compression is

related to force, duration and raterelated to force, duration and rate

• Emergent therapy is necessaryEmergent therapy is necessary

• ““Spinal Cord Attack”Spinal Cord Attack”

Brad Bunney, MD

First line of therapy for epidural spinal cord First line of therapy for epidural spinal cord compression from metastatic cancer is:compression from metastatic cancer is:

A.A. Radiation therapyRadiation therapy

B.B. Surgery Surgery

C.C. Corticosteroids Corticosteroids

D.D. ChemotherapyChemotherapy

Brad Bunney, MD

The most common site of epidural spinal cord The most common site of epidural spinal cord compression from metastatic cancer is:compression from metastatic cancer is:

A.A. Cervical spineCervical spine

B.B. Thoracic spineThoracic spine

C.C. Lumbar spineLumbar spine

D.D. Sacral spineSacral spine

Brad Bunney, MD

All of the following are indications for non-All of the following are indications for non-operative treatment of spinal epidural abscesses operative treatment of spinal epidural abscesses

except:except:

A.A. Pan-spinal involvementPan-spinal involvement

B.B. Lumbosacral SEA and normal neurological Lumbosacral SEA and normal neurological examexam

C.C. Fixed neurological deficits for greater than 48 Fixed neurological deficits for greater than 48 hrshrs

D.D. Urinary incontinence and sensory deficitUrinary incontinence and sensory deficit

Brad Bunney, MD

All of the following contribute to the severity of All of the following contribute to the severity of spinal cord compression except:spinal cord compression except:

A.A. Force of compressionForce of compression

B.B. Length of spinal cord compressedLength of spinal cord compressed

C.C. Duration of compressionDuration of compression

D.D. Rate of compressionRate of compression

Brad Bunney, MD

The most common organism cultured in spinal The most common organism cultured in spinal epidural abscesses is:epidural abscesses is:

A.A. StreptococcusStreptococcus

B.B. PseudomonasPseudomonas

C.C. Staphylococcus aureusStaphylococcus aureus

D.D. KlebsiellaKlebsiella

E.E. Mycobacterium tuberculosisMycobacterium tuberculosis