Critical Care and ER Lower Back Emergencies

8/9/2019 Critical Care and ER Lower Back Emergencies

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“A disconcertingcause of back

pain”Chidinma Chima-Melton

Critical Care ConferencePulmonary & Critical Care


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Objecties

•!eie" a case of seere lo"back pain in a critical care

setting•Appreciate the importance ofthe history and physical in

assessing lo" back pain•!eie" the emergency causesof lo" back pain# including the

"ork-up and management


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$ho is this%


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$illiam Osler '()*+'*'*,

• Canadian physician and ather of

Modern Medicine• our founding professors of .ohns/opkins /ospital

•

Osler created the 0rst internalmedicine residency program

• Pioneer of bedside teaching for

medical students


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Case PresentationChief Complaint:

1ack painHPI

• 23 year old man "ho presents "ith seerelo"er back pain

• irst noted pain "hen "alking dog ) daysprior to admission

• Came to 45 + gien de6amethasone#

toradol and dilaudid• 7ent home "ith mobic# medrol dose pack

and percocet

• $ent to an outpatient clinic and receied a

steroid hip injection


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Case Presentation cont8d

• Pain did not improe + in fact it got"orse

• $as unable to ambulate due to pain

• Pain "as sharp# in left lo"er back9:ankradiating to groin

• On admission denies any chills# omiting

• !O7; Positie for subjectie feers#diarrhea# "eight loss# nausea and poorPO intake<


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Past Medical /istory

• /=>

• 5egeneratie .oint 5isease

• Psoriatic arthritis

• An6iety and 5epression

• /ypercholesterolemia

• 1enign Prostatic /yperplasia

• ?ocal Cord 5isease

• 7leep Apnea but does not use CPAP


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Medications

• A7P@!@> (' M 4C =A1B4=

• A=O!?A7=A=@> ' M O!AB =A1B4=

• CA!@7OP!O5OB 7OMA,

• @>A7=4!@54 D M O!AB =A1B4=

• M4BOE@CAM 'D M O!AB =A1B4=

• M4=OP!OBOB D M 4E=4>545-!4B4A74 =A1B4=

• OEFCO5O>4

• =4!AGO7@> ' M CAP7HB4

• ?AB7A!=A> '2 M O!AB =A1B4=


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7ocial /istory & amily /6

Social History

• /e "orks as an accountant

• Bies "ith his roommate

• =he patient denies any tobacco use + neersmoker# no alcohol use<

• 5enies any recreational and @? drug use

Family History

• Mother + 5ementia

• ather - 4mphysema


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$hat is the diNerential diagnosis for his

lo" back pain%


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Anatomy of the Bumbar7pine

41 Medicine K'3


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41 Medicine K'3


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Babs on admission

• =roponin '


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Bumbar E-ray obtained

in 45 K days beforeadmission


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M!@ Bumbar spine no gadolinium,in 45 K days before admission


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/ospital Course

• Admitted to the medical :oors

• 7tarted on pain control "ith o6ycodone# dilaudidand muscle rela6ants roba6in

• !eie"ed M!@ lumbar spine

• P= ealuation

• /ome medications continued


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5ay K

• 1ecame hypotensie# febrile# abdomen becamedistended# deeloped bloody diarrhea# nausea#omiting and epigastric pain<

• Bactate eleated 3= output suspicious for coNee ground emesis

•

/e "as transferred to the @CH shortly thereafterfor continuing care<

• QH1 performed this morning demonstrated dilatedloops of bo"el concerning for ileus s 71O# no freeair<


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Babs on @CH transfer

• =roponin @ '


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CE! on =ransfer


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5ay K Continued

• Central line placed and ?asopressors started

• 7urgery consult for concern for 71O + recommend>= to suction decompress,

• 1road spectrum antibiotics ancomycin and

Rosyn @?, initiated• @ consulted for H@1 + PP@ started

• ==4 negatie for ?egetation

• Bo" back pain continued + Pain management

consulted


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Problem Bist 5ay 3 @CH

• 7eptic 7hock reSuiring asopressors

• >odules# consolidations and pleural eNusions onC= Chest

• 71O s ileus

• =hrombocytopenia

• Beukopenia

• AQ@

• >7=4M@

• =ransaminitis• 46cruciating back pain

• A0b "ith !?!


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$/A= @7 =/4 5@4!4>=@AB 5@A>O7@7O! 1ACQ PA@> A= =/@7 =@M4%


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$/A= $O!Q HP $OHB5 FOH

O1=A@> A= =/@7 PO@>=%


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5ay )

• Cultures remained positie for M77A

• HA suggestie of M77A

• $1C scan performed;

'< indings consistent "ith osteomyelitis at =)-=D and

B3-B) as described aboe<K< indings suspicious for in:ammatory9infectiousprocess of the left hip<

3< @nfectious process of the right mid and left lo"erlung<

)< Bikely in:ammatory9infectious process of the colon<

• Cr< @mproed so M!@ "ith ad obtained


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=K "eight thoracic sag

=)-=D osteomyelitis and probable disc space infection "ith anepidural


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=K "eight 7ag Bumbar

5isc space infection B3-) "ith epidural pannus e6tending from B' to BD

"ith moderate central canal stenosis at B3 and B)< @nolement of bothpsoas muscles<


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/ospital Course continued

• Came oN pressors and "as able to leae the @CH

• Beft hip arthrocentesis and :uid gre" M77A

• 45 demonstrating duodenal ulcers and multiplegastric ulcers

• 1lood cultures eentually steriliRed after ' "eek• 1ack pain improed after draining psoas abscess

• 71O improed and diet adanced

• Beukopenia and thrombocytopenia improed

• 7pine consulted conseratie management


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5iagnosis

=)-=D osteomyelitis# B3-B) diskitis and epiduralphlegmon "ith mild cord compression

M77A 1acteremia "ith H=@ and pulmonary

dissemination

B hip M77A 7eptic Arthritis


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Acute Bo" 1ack Pain

• Bo" back pain is the most common type of painreported by adults in the Hnited 7tates

• K2L of the population reporting pain lasting atleast a day in the past 3 months

• 'L of the Hnited 7tates "orkforce considered“permanently disabled” by lumbago<

• @n '**(# direct healthcare costs attributed tolo"er back pain - estimated at T* billion

0 i i


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5e0nitions; Acute Bo"1ack Pain• Acute lo" back pain; 7ymptoms lasting )

"eeks up for 3 months,

• Chronic 1ack pain; Pain syndrome lasting longerthan 3 months<

• 7ciatica; Beg pain that localiRes to lumbar sacral

nere roots*L of pathology occurs at B)-BD andBD-7' leels


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5e0nitions; Acute Bo"1ack Pain• 7pinal stenosis; Cro"ding of the spinal canal#

either by osteoarthritis# osteophytes# ligamentousthickening# and9or bulging interertebral discs

• Myelitis; An in:ammatory condition that aNectsthe spinal cord< often "hite matter anddemyelination are inoled,

•

Cauda eSuina syndrome; Compression of thecauda nere roots,

• 7pondylolisthesis; ?ertebra slips out of position inrelation to the ertebra beneath it<


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4aluation of the lo" back painpatient

Clinicians should conduct a focused history andphysical e6amination to help place patients "ith lo"back pain into ' of 3 broad categories;

'< !ed lag lo" back pain potentially serious,

K< 1ack pain potentially associated "ithradiculopathy or spinal stenosis

3< >onspeci0c back pain most common,

strong recommendation# moderate-Suality

eidence,<

Ann @ntern Med< KIU')II,;)I(-)*'

Ph i l 4 i A


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Physical 46am in AcuteBumbago• @t is fundamental to perform a systematic

neurologic e6amination<

• @nclude pertinent negaties and positiesregarding strength# sensory# re:e6es# gait# rectal

sensation e6amination and assessment for urinaryretention

• =he P4 0ndings or lack of 0ndings, should be thefoundation of the decision to pursue imaging

• More than *L of disc herniations occur at theB)9BD or BD97' leels so a focus on this leel


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$hen to Obtain imaging

• Most lo" back pain self resoles in ) to 2 "eeks soimaging is not recommendedV in patients "ithout red:ags

• A meta-analysis of 2 randomiRed trials of '(patients found no outcome diNerences bet"eenroutine care and no imaging and patients "hounder"ent imaging "ith plain 6-ray# C=# or M!@

• Additionally# M!@ reeals many abnormalities in

asymptomatic patients<

• @n a study of asymptomatic patients aged W 2# 32Lhad a herniated disc# K'L had spinal stenosis# and*L had a degenerated or bulging disc<


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Plain !adiographs

• !outine plain 0lms are not indicated - ery lo" foran interenable lesion or pathology

• @n a study of 2(# radiographs# clinically

unsuspected lesions occurred in ';KD patientsaged K to D years<

• E-ray is recommended in patients "ho hae;

•

5irect trauma-related back pain• 7uspected of haing a possible ertebral

compression fracture

• Foung patients "ith lo"er back pain "hereankylosing spondylitis is suspected

Aft C ti


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After ConseratieManagement• @n patients "ith lo" back pain and radiculopathic

symptoms "ho are still symptomatic after )"eeks of conseratie management and self-care

• @maging should be discussed that can be

interened upon i


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$@=/ =/4 /@/ P!4?AB4>C4 O BHM1AO#$/4> 5O47 @= 14COM4 A> 4M4!4>CF%


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=K-"eighted sagittal M!@ of the spine


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g g psho"ing osteomyelitis at ='K top arro",and partial cord compression at B' bottom

arro",<

AAP

A t B 1 k P i


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Acute Bo" 1ack Pain4mergencies• Cauda 4Suina 7yndrome

• Abdominal Aortic Aneurysm !upture

• 7pinal /ematoma

• 4pidural Abscess

• @n CA74 of 4mergencyX


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Cauda 4Suina 7yndrome•

Cauda eSuina proide motor and sensory functionto the lo"er e6tremities# perineum# and bladder<

• /erniated disks are most common lesions causingcauda eSuina syndrome

•

Other causes are tumors# spinal stenosis#infection# and hematoma

• Presentation; lo" back pain# b9l "eakness in lo"ere6tremities# saddle anesthesia# and abnormalitiesin bladder sensation and function completeersus incomplete syndromes,

• =@P; Measure post oid residual P?!,< P?! 3ml is al"ays abnormal<

• 5iagnosis; M!@ or C= myelogram is needed to

make this diagnosis<


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Abdominal Aortic Aneurysm!upture

• Abdominal aortic diameter 3 cm is aneurysmal'9' patients,

• Abdominal aortic aneurysms are uncommon inpatients aged 2 years<

•

An aneurysm8s siRe correlates "ith risk of rupture•


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7pinal /ematoma• =@P; 7pinal epidural hematomas are rarely

spontaneous< Hsually related to trauma#postoperatie spinal surgery#anticoagulation# thrombolysis# lumbarpuncture# epidural anesthesia#ascular

malformation# or chiropracticmanipulation<

• Presentation; 1ack pain and possible

neurologic complaints• 5iagnosis; A lo" threshold for imaging

"ith M!@ "ith ad or C= myelogram "ithcontrast is needed in suspected patients

• !eerse of coagulopathy# and patients


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4pidural Abscess

• 4pidural abscess is a rare condition


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4pidural AbscessBocations


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4pidural Abscess

• Posterior epidural abscesses tend to be related toa distant focus

• Anterior infections are generally related toosteomyelitis or diskitis "hich can be related to a

distant focus or contiguous spread# such as psoasabscess,

• Presentation; >onspeci0c - can include feer#back pain# and malaise

• 5iagnosis; M!@ "ith gad preferred, or C=

myelogram"ith contrast

• =reatment; )-2 "eeks antibiotics and considersurgical decompression<

i l id l b i


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7pinal 4pidural Abscess - 46perience"ith )2 Patients

• Chart reie" )2 patients 32 men and ' "omen, "ithspinal epidural abscess oer a '-year period

• !isk factors; diabetes )2L,# freSuent enouspuncture 3DL,# spinal trauma K)L,# and history of

spinal surgery KKL,• 47! "as eleated uniformly mean# (2


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$illiam Osler

ZBisten to your patient# for he is telling you thedia nosisZ


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!eferences•

Andersson 1< 4pidemiological features ofchronic lo"-back pain< Bancet<'***U3D)*'I(,;D('-D(D< !eie",

• Chou !# [aseem A# 7no" ?# et al< 5iagnosis andtreatment of lo" back pain; a joint clinicalpractice guideline from the American College ofPhysicians and the American Pain 7ociety< Ann@ntern Med< KIU')II,;)I(-)*'< Clinicalpractice guideline,

• >@C4< >ational @nstitute for /ealth and Clinical46cellence - lo" back pain C((,< K*< Clinicalpractice guideline,

• An 4idence-1ased Approach =o =he 4aluation

And =reatment Of Bo" 1ack Pain @n =he


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Critical Care and ER Lower Back Emergencies

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