Back Pain


Adole-
cent
   Spondylolithiasis
30
yr
old
Straight Leg Test -  VERTEBRAL OSTEOMYELITIS Hx of IV Drug use 
 
MRI
 
Strain/ Sprain

 = NSAID , +/- Muscle relaxers & Mobility (4-6 wk).   If no improvement, do CT/MRI

+
 
Disk Herniation
 

Neuro Exam
 

-  NSAID, muscle relaxer & Mobility (4-6 wk).
If no improvement, do CT/MRI
+

 
Emergency Decompression

 
Fever

 = MRI

Epidural Abscess
 
ABx + Surgery
 
Vertebral Osteomylitis
 
(-) Straight leg test
Hx of IV Drug Use
 
60
yr
old

 

On Prednisone Compression Fx - Demineralised Bone
- Emergency
Constant Pain Metastatic Cancer - PSA?
- Pain worse at night
Worse w/ walking
Improve w/ sitting
Spinal Stenosis - MRI
- Emergency
Hearing Loss Paget's Disease - Alk Phis
- OsteoCLAST activity
- "Mosaic"
- Femoral bowing
- OsteoSARCOMA
- Vestibulocochlear nerve compression


 

Low Back Pain
-The causes of low back pain are varied and often impossible to pinpoint in the emergency department.
-It is more important to determine if an emergency exists that requires neurosurgical intervention or a condition, e.g, osteomyelitis that requires specific treatment.
-Patients at high risk for a serious cause of back pain include injection drug users, the elderly, immunocompromised, and those with a history of cancer or recent trauma.

SYMPTOMSTOMS
Symptoms that indicate a potential neurosurgical emergency include:
    Fever
  • Severe pain, which may be radicular
  • Neurological impairmentment
  • Bladder or bowel retention or incontinence

EXAM

    Exam includes
    • Inspection (e.g., loss of normal lordosis)
    • Palpation (e.g., midline tenderness vs. paraspinal tenderness)
    • ROM, Muscle testing, Reflexes, and Sensation ion
       
  • Red flags in conjunction with neck or back pain include
    • Night pain and weight loss (think tumor);
    • Fevers, chills, and sweats (think bone or disk infection);
    • Acute bony tenderness (think fracture);
    • Morning stiffness lasting> 30 minutes in young adults (think seronegative spondyloarthropathy);
    • Any neurologic deficit or bowel/bladder involvement (think nerve root compromise).
      • Urinary or fecal incontinence
      • Urinary retention
    • Cancer metastatic to bone (breast, lung, thyroid, renal, prostate)
    • Progressive lower extremity motor or sensory loss
    • Significant trauma related to age
    • Severe pain and lumbar spine surgery in the prior 12 months
       
  • Findings that indicate a neurosurgical emergency, including:
    • Motor weakness
    • Loss of perianal/perineal sensation
    • Loss of deep tendon reflexes
    • Spurling test:
      • The patient extends the neck and tilts the head to the side while the examiner presses down on the head. This narrows the patient's neural foramen and will worsen or reproduce radicular pain due to disk herniation or cervical spondylosis.
    • Straight leg raise test (SLR):
      • A positive SLR is back pain that radiates past the knee at an elevation < 60 degree.
      • A positive contralateral SLR is highly specific for sciatica.
    • Decreased rectal tone

DIFFERENTIAL

  • Back strain
  • Herniated disc
  • Osteomyelitis
  • Epidural abscess
  • Aortic aneurysm
  • Kidney stone/infection
  • Cancer
  • Fracture
  • Spinal stenosis

DIAGNOSIS

  • History and exam are critical!
  • Lumbosacral X-rays are generally overused but should be considered if:
    • Patient's age >55
    • Trauma with vertebral tenderness
    • Pain lasting longer than 1 month
    • History of IV Drug Use
    • Suspicion for cancer or infection such as fever or weight loss
  • CT scan and MRI are more sensitive for infection and cancer.
  • MRI better for herniated discs and neurological impairment

TREATMENT

  • Treat underlying cause.
  • If musculoskeletal in origin:
    • Ice in first 24-72 hours; afterward, heat may be helpful.
    • Pain medication
      • Naprosyn 500mg po q12h
      • Diclofenac Potassium 50mg po tid
      • Melocixam 7.5 - 15 mg po qd
    • Muscle relaxants
      • Skelaxin 800mg po tid on empty stomach
      • Cyclobenzaprine 5mg po tid (qd in elderly pts). Duration: 2-3 wks
      • Robaxin 500mg 2 tabs po qid
      • Zanaflex 4mg po q6-8h prn spasticity
    • Activity as tolerated: Neither complete bedrest nor active physical therapy that causes pain is helpful./b>.
  • Neurosurgical or spine specialist consultation if any neurological impairment