3/21/2014 Back to the ED When back pain is a true emergency Jason Kodat, MD, EMT-P Associate Medical Director, Forbes Regional Hosp Emergency Physician, EMP of Alle-Kiski 1 3/21/2014 Objectives • Back anatomy • Low-risk symptoms • Red flag signs & symptoms Back anatomy The back • • • • • Spine Spinal cord Nerve roots Musculature Ribs (more of a middle-upper back problem) • Skin User StephAknee(: of weheartit.com 2 3/21/2014 The Spine • Vertebrae – 7 cervical – 12 thoracic – 5 lumbar • Sacrum • Coccyx Vertebral bones • • • • • Body Facets Intervertebral foramen Lateral processes Spinous process Wikimedia Commons 3 3/21/2014 Spinal cord • Cervical & lumbar enlargements • Ends around L1-L2 – Conus medullaris – Filum terminale – Spinal canal continues to sacrum Spinal cord • Meninges, same as brain – Pia mater – Arachnoid – Dura mater • CSF Spinal cord University of Manitoba 4 3/21/2014 Nerve roots • Exit between each vertebral pair, and through sacrum & coccyx – – – – – 8 cervical 12 thoracic 5 lumbar 5 sacral 1 coccygeal Wikimedia Commons Nerve roots • Cauda equina – L2 root and lower John A Beal, PhD; Dept. of Cellular Biology & Anatomy, LSU Health Sciences Center Shreveport Nerve roots • Split dorsal/ventral – Dorsal: motor – Ventral: sensory • Great toe raise: L5 • Plantar flexion: S1 Hydrorush Water Treatment 5 3/21/2014 Superficial musculature http://myoursaddhana.blogspot.com Deep musculature Certified Angus Beef Emory Univ. Things that aren’t “back” but can hurt there • • • • • • Aorta Gall bladder Liver Stomach Spleen Kidney/ureter Moore KL, Dalley AF. Clinically Oriented Anatomy. 6 3/21/2014 http://www.braincells4rent.com Low-risk signs & symptoms Low risk: none of these • • • • • • Hx of cancer Hx of weight loss Fevers Night sweats IV drug use Saddle anesthesia • • • • • • Recent infection Known AAA Motor deficit Immunocompromise Urinary retention Bowel incontinence 7 3/21/2014 More good signs • History of trauma • History of – – – – Lifting Pulling Pushing Stretching • Tender on paraspinous muscles • Urinary symptoms Non-back causes of back pain • • • • • • • Renal colic Biliary colic Pyelonephritis Pancreatitis Ulcer Endometriosis Zoster • • • • • • • Colicky pain, hematuria RUQ tenderness Urinary complaints Epigastric tenderness Abd radiating to back Recurrent, female Rash Red flag signs & symptoms 8 3/21/2014 Red flags • • • • • Fever Weight loss Neuro deficits Hypotension Syncope • History of – – – – – – Trauma Infection Cancer Spinal procedures IV drug use AAA Spinal epidural abscess Spinal epidural abscess • Infection in epidural space • Anterior: osteomyelitis or discitis • Posterior: seeding from distant infection JAAOS May/June 2004 vol. 12 no. 3 155-163 9 3/21/2014 Spinal epidural abscess • Risk factor search (80%) – Immunocompromise – IV drug use – Prolonged steroid – Recent spinal procedures – Recent bacterial infection • Persistent fevers or night sweats • May have local tenderness AAA http://www.neatorama.com AAA • Back pain + hypotension or syncope = AAA until proven otherwise • Uncommon in pts <60 years old • Also concerning: – Diaphoresis – N/V – Abdominal pain 10 3/21/2014 Cauda equina syndrome http://bank.imgdumpr.com Cauda equina syndrome • Compression of cauda equina • Disc herniation most common cause – Also infection, cancer, traumatic, iatrogenic • Often slow onset BMJ 2009;338:b936 Cauda equina syndrome • • • • • • Back pain Saddle anesthesia Urinary retention Bowel incontinence Diminished reflexes Leg weakness 11 3/21/2014 Spinal epidural hematoma Spinal epidural hematoma • Back pain ± neurologic complaints • Rarely spontaneous – – – – – Trauma Anticoagulants LP/epidural anesthesia Chiropractic Spinal surgery • Can cause cauda equina syndrome Cancer 12 3/21/2014 Cancer • Back pain ± neurologic complaints • May have h/o cancer or unexplained weight loss • Rarely may cause cauda equina syndrome • Pathological fx 13