Case Presentation Dave Choi PGY-4 Emergency Medicine Edmonton Dave Choi PGY-4 Emergency Medicine Edmonton.

Case PresentationCase Presentation

Dave ChoiPGY-4

Emergency MedicineEdmonton

Dave ChoiPGY-4

Emergency MedicineEdmonton

Learning GoalsLearning Goals

Present an interesting case

Briefly review relevant material

Be done in 25 minutes… really.

Present an interesting case

Briefly review relevant material

Be done in 25 minutes… really.

The CaseThe Case

Day shift at the Foothills Just finished resusitating a level 1

trauma patient Feeling good about your intubation

and chest tube skills, you move to the minor side to see a patient with “low back pain”

Day shift at the Foothills Just finished resusitating a level 1

trauma patient Feeling good about your intubation

and chest tube skills, you move to the minor side to see a patient with “low back pain”

HistoryHistory

Mr G. 58 y.o. male Walked into ER c/o lower back pain x 1/12 Seen by GP last week given toradol

and percocet, also put on Flomax for BPH

Mr G. 58 y.o. male Walked into ER c/o lower back pain x 1/12 Seen by GP last week given toradol

and percocet, also put on Flomax for BPH

HistoryHistory

Noticed lower back pain at night initially No history of trauma Constant pain Mildly relieved by hot compresses, and

pain medications Activity doesn’t make it better or worse Wakes him up at night sometimes

Noticed lower back pain at night initially No history of trauma Constant pain Mildly relieved by hot compresses, and

pain medications Activity doesn’t make it better or worse Wakes him up at night sometimes

HistoryHistory

Pain has been getting bit worse Worse with coughing, straining Radiating to flank/groin x 1/52 Some voiding difficulty (hard start)

x 1/52 No bowel incontinence

Pain has been getting bit worse Worse with coughing, straining Radiating to flank/groin x 1/52 Some voiding difficulty (hard start)

x 1/52 No bowel incontinence

HistoryHistory

No fever, chills, night sweats ~5lb weight loss over last couple

months

No fever, chills, night sweats ~5lb weight loss over last couple

months

Red FlagsRed Flags

Pain not relieved by lying down Night pain Leg weakness Bowel, bladder, sexual symptoms Fever (esp. IVDU) Weight loss

Pain not relieved by lying down Night pain Leg weakness Bowel, bladder, sexual symptoms Fever (esp. IVDU) Weight loss

HistoryHistory

PmHx: ↑ cholesterol Meds: Crestor 10mg PO QD,

Percocet 1tab PO Q4H prn, Toradol 10mg PO Q6H prn

Allergies: NKDA FHx: father MI at 80 y.o.

PmHx: ↑ cholesterol Meds: Crestor 10mg PO QD,

Percocet 1tab PO Q4H prn, Toradol 10mg PO Q6H prn

Allergies: NKDA FHx: father MI at 80 y.o.

HistoryHistory

SHx- non smoker- occas. EtOH- no illegal drugs- worked as senior manager for Telus, retired

earlier this year, exercises 3x/week, going on holidays soon

ANY OTHER QUESTIONS? Ddx?

SHx- non smoker- occas. EtOH- no illegal drugs- worked as senior manager for Telus, retired

earlier this year, exercises 3x/week, going on holidays soon

ANY OTHER QUESTIONS? Ddx?

O/EO/E

Vitals: T36.8, P54, RR15, BP137/83, Sat 99% Heart S1S2, no EHS/murmurs/rubs Lungs clear, AE=AE Abd soft, normal BS, bit tender

suprapubic, no peritoneal signs/guarding

No pulsating mass, no flank tenderness

Vitals: T36.8, P54, RR15, BP137/83, Sat 99% Heart S1S2, no EHS/murmurs/rubs Lungs clear, AE=AE Abd soft, normal BS, bit tender

suprapubic, no peritoneal signs/guarding

No pulsating mass, no flank tenderness

MSK ExamMSK Exam

No erythema/warmth/swelling over back Pain is midline but not worse with

palpation No atrophy legs Normal SLR tests (Lasegue’s) Normal ROM lower back (Schober’s) Normal gait

No erythema/warmth/swelling over back Pain is midline but not worse with

palpation No atrophy legs Normal SLR tests (Lasegue’s) Normal ROM lower back (Schober’s) Normal gait

Neuro ExamNeuro Exam

Motor: 5/5 power UE, Slight decreased power L hip flexor, otherwise normal

Sensation: normal UE/LE, no saddle anesthesia, normal rectal tone, mild prostate enlargement

DTR +2 bilat UE, +1 bilat LE, no Babinski

Motor: 5/5 power UE, Slight decreased power L hip flexor, otherwise normal

Sensation: normal UE/LE, no saddle anesthesia, normal rectal tone, mild prostate enlargement

DTR +2 bilat UE, +1 bilat LE, no Babinski

InvestigationsInvestigations

Xray Lspine - mild degen changes

Hgb158 WBC5.9 Plt 243 Na140 K4.1 Cl105 bicarb27 Cr100, Urea5.5

Urine neg leuks/protein/hgb

Bladder scanned for 154ml

Xray Lspine - mild degen changes

Hgb158 WBC5.9 Plt 243 Na140 K4.1 Cl105 bicarb27 Cr100, Urea5.5

Urine neg leuks/protein/hgb

Bladder scanned for 154ml

Differential Dx Low Back Pain

Differential Dx Low Back Pain

Mechanical (>95%)- Lumbar strain (70%), degenerative process (10%), herniated disk

(4%), spinal stenosis (3%), OP compression # (4%), spondylolisthesis (2%), traumatic # (<1%), congenital disease (<1%), disc disruption

Non-mechanical spinal conditions (~1%)- Neoplasia, infection, inflammatory arthritis, Paget’s

Visceral disease (~2%)- Disease of pelvic organs, renal disease, AAA, GI

Mechanical (>95%)- Lumbar strain (70%), degenerative process (10%), herniated disk

(4%), spinal stenosis (3%), OP compression # (4%), spondylolisthesis (2%), traumatic # (<1%), congenital disease (<1%), disc disruption

Non-mechanical spinal conditions (~1%)- Neoplasia, infection, inflammatory arthritis, Paget’s

Visceral disease (~2%)- Disease of pelvic organs, renal disease, AAA, GI

PLANPLAN

D/C home?

Any other investigations?

- FAST (aorta)

Follow up?

D/C home?

Any other investigations?

- FAST (aorta)

Follow up?

10 days later…10 days later…

Patient sent into ER from GP’s office for in/out cath and urinalysis

Lower abdominal discomfort Cannot sleep

Patient sent into ER from GP’s office for in/out cath and urinalysis

Lower abdominal discomfort Cannot sleep

Physical ExamPhysical Exam

Chest clear Abd: bit distended, dull to percussion,

suprapubic discomfort to palpation, symmetric fullness

Neuro exam unchanged from previous Bladder scanned for 550ml, foley

drained 500ml, foley left in

Chest clear Abd: bit distended, dull to percussion,

suprapubic discomfort to palpation, symmetric fullness

Neuro exam unchanged from previous Bladder scanned for 550ml, foley

drained 500ml, foley left in

10 days later…10 days later…

Urinalysis: 3+ leuks, many bacteria Started on Septra Discharged home with U/S pelvis

booked for next day

Urinalysis: 3+ leuks, many bacteria Started on Septra Discharged home with U/S pelvis

booked for next day

PLANPLAN

Leave catheter in Toradol 30mg IM Buscopan 10mg POPatient feels bit

better

• U/S pelvis tomorrow

Leave catheter in Toradol 30mg IM Buscopan 10mg POPatient feels bit

better

• U/S pelvis tomorrow

It’s tomorrowIt’s tomorrow

U/S abdo/pelvis – normal GB + bile ducts, liver grossly normal, pancreas, spleen, aorta normal, multiple bilateral renal cysts, but kidneys otherwise normal

Now what?

Dx = prostate hyperplasia, UTI, and mechanical back pain

U/S abdo/pelvis – normal GB + bile ducts, liver grossly normal, pancreas, spleen, aorta normal, multiple bilateral renal cysts, but kidneys otherwise normal

Now what?

Dx = prostate hyperplasia, UTI, and mechanical back pain

Case continuedCase continued

Urology consult for cystoscopy as outpatient

Urology consult for cystoscopy as outpatient

28 days later28 days later

Still c/o back pain worse at night Very tender suprapubic area Numbness / tingling feet started 1

week ago Meds: Flomax, Proscar, Flexeril,

Percocet prn, Toradol prn

Still c/o back pain worse at night Very tender suprapubic area Numbness / tingling feet started 1

week ago Meds: Flomax, Proscar, Flexeril,

Percocet prn, Toradol prn

28 days later28 days later

O/E: AVSS Neuro Exam- Motor: 4+/5 hip flexors, others 5/5- Sensation: “numb” over plantar feet

bilat, touch/pinprick ok- DTR +1 LE bilat, +2 UE bilat, no

Babinski- No saddle anesthesia- Rectal tone intact

O/E: AVSS Neuro Exam- Motor: 4+/5 hip flexors, others 5/5- Sensation: “numb” over plantar feet

bilat, touch/pinprick ok- DTR +1 LE bilat, +2 UE bilat, no

Babinski- No saddle anesthesia- Rectal tone intact

Case continuedCase continued

Working Dx = Urinary retention 2o to BPH and LBP (mechanical)

Working Dx = Urinary retention 2o to BPH and LBP (mechanical)

Hmm…Hmm…

Pt returns to ED 3 more times in the next 4 days c/o urinary retention and suprapubic discomfort

Now c/o bilateral numbness/tingling feet and lower back pain radiating to bilateral thighs

Pt returns to ED 3 more times in the next 4 days c/o urinary retention and suprapubic discomfort

Now c/o bilateral numbness/tingling feet and lower back pain radiating to bilateral thighs

InvestigationsInvestigations Pt booked for outpt MRI L-spine

for ?neurogenic claudication by GP

Cystoscopy – mildly enlarged prostate

Pt booked for outpt MRI L-spine for ?neurogenic claudication by GP

Cystoscopy – mildly enlarged prostate

2 weeks later…2 weeks later…

Returns to ED c/o gradual bilateral leg weakness L>R

Has been unable to walk independently over last 4 days (using walker)

Foley catheter in situ x 3 weeks Unable to cope at home

Returns to ED c/o gradual bilateral leg weakness L>R

Has been unable to walk independently over last 4 days (using walker)

Foley catheter in situ x 3 weeks Unable to cope at home

Recap of the EventsRecap of the Events LBP, gradual onset and worsening, night

pain, worse with valsalva x 4/12 Pain radiating to bilat thighs and groin x

3/12 Numbness/tingling bilat feet, ascending

from feet to thigh x 1/12 Urinary retention x 1/12, indwelling

foley x 3/52 Gradual bilateral leg weakness x 2/52

LBP, gradual onset and worsening, night pain, worse with valsalva x 4/12

Pain radiating to bilat thighs and groin x 3/12

Numbness/tingling bilat feet, ascending from feet to thigh x 1/12

Urinary retention x 1/12, indwelling foley x 3/52

Gradual bilateral leg weakness x 2/52

Neuro Exam NowNeuro Exam Now

Motor: UE normal; 3/5 Hip flexors, 3+/5 Quads, 4/5 Hamstrings, 4/5 ankle dorsi/plantarflexion

Sensation: saddle anesthesia! Reflexes: no DTRs LE, no Hoffman’s, no

Babinski, normal bulbocavernosus reflex and rectal tone

Motor: UE normal; 3/5 Hip flexors, 3+/5 Quads, 4/5 Hamstrings, 4/5 ankle dorsi/plantarflexion

Sensation: saddle anesthesia! Reflexes: no DTRs LE, no Hoffman’s, no

Babinski, normal bulbocavernosus reflex and rectal tone

Case continuedCase continued

Admitted under neurosurgery MRI – syrinx vs inflammatory or

neoplastic cord disease, suggest LP by neurology to r/o viral etiology

Lumbar Puncture – WBC103 RBC96 Prot4.15 (<0.45) Glu2.6 (2.2-4.4) neg cultures

Diagnosis?

Admitted under neurosurgery MRI – syrinx vs inflammatory or

neoplastic cord disease, suggest LP by neurology to r/o viral etiology

Lumbar Puncture – WBC103 RBC96 Prot4.15 (<0.45) Glu2.6 (2.2-4.4) neg cultures

Diagnosis?

CaseCase

CT chest/abd – no aortic dissection

MRA – suspicious for dural AV fistula arising from upper lumbar region causing ischemia

OR – L2-4 laminectomy and clipping of spinal dural AV fistula

CT chest/abd – no aortic dissection

MRA – suspicious for dural AV fistula arising from upper lumbar region causing ischemia

OR – L2-4 laminectomy and clipping of spinal dural AV fistula

Dural AV fistulaDural AV fistula

a.k.a. Foix-Alajouanine Syndrome AV malformation of spinal cord vessels,

usually lower thoracic or lumbosacral Can lead to ischemic injury of the cord Male:Female 4:1 Usually >50yo Symptoms gradual onset over months

to years

a.k.a. Foix-Alajouanine Syndrome AV malformation of spinal cord vessels,

usually lower thoracic or lumbosacral Can lead to ischemic injury of the cord Male:Female 4:1 Usually >50yo Symptoms gradual onset over months

to years

Symptoms / SignsSymptoms / Signs- Weakness / numbness / tingling of LE- Gradual onset + worsening LE weakness- Urinary / fecal incontinence- lower back pain +/- radiating- Abnormal gait- Spastic or flaccid paraparesis +/-

sensory level - DTR variable; +/- Babinski- Decreased rectal tone

- Weakness / numbness / tingling of LE- Gradual onset + worsening LE weakness- Urinary / fecal incontinence- lower back pain +/- radiating- Abnormal gait- Spastic or flaccid paraparesis +/-

sensory level - DTR variable; +/- Babinski- Decreased rectal tone

Investigation / TreatmentInvestigation / Treatment

INVESTIGATION MRI Myelogram angiography

TREATMENT Embolization of AVM Laminectomy w/ obliteration of AV

shunt

INVESTIGATION MRI Myelogram angiography

TREATMENT Embolization of AVM Laminectomy w/ obliteration of AV

shunt

CaseCase Electrodiagnostic Study

- Axonal injury to leg muscles L>R

- Considerable # motor neurons still intact, prognosis for functional recovery reasonably good

Electrodiagnostic Study

- Axonal injury to leg muscles L>R

- Considerable # motor neurons still intact, prognosis for functional recovery reasonably good

Mr. G nowMr. G now

Back pain significantly reduced Unable to ambulate Self in/out catheterizations BMs ok

Still hoping to go on planned holidays to Hawaii in the future

Back pain significantly reduced Unable to ambulate Self in/out catheterizations BMs ok

Still hoping to go on planned holidays to Hawaii in the future

?

SummarySummary

Red flags for Low back pain

Multiple ER visits with same problem, do not get blinded by the “diagnosis”

Red flags for Low back pain

Multiple ER visits with same problem, do not get blinded by the “diagnosis”