Telling your story through photography and film Heidi

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
`