EMCrit.org

Back Pain and Spinal Cord/Soft Tissue Injuries

Must Exclude Diagnoses of Back Pain

CRAFTI

Cauda Equina

Ruptured Disk

AAA

Fracture

Tumor

Infection (spinal epidural abscess)

Good data that a single lateral lumbo-sacral spine film is as good as three view series.  One set of LS spine films gives the same amount of gonadal irradiation as 6 years of daily PA/LAT C-XRs (Br J Radiology 1990 Jul; 63(751))

Large randomized trial of MRI vs. radiographs showed no advantage to doing mri as initial test (JAMA. 2003;289:2810-2818.)

fever, unexplained weight loss, a history
of cancer, neurologic deficits, alcohol or injection-drug
abuse, an age of more than 50 years, or trauma. Failure
of the pain to improve after four to six weeks
should prompt radiography,"Red flags" that suggest a need for early imaging include major trauma, an age above 50, history of cancer, unexplained weight loss, fever, immune deficiency or suppression, injection drug use, active infection, saddle anesthesia, bladder or bowel incontinence, and/or a severe or progressive neurologic deficit
 

Leg pain>back pain, consider disc herniation

Testing

L4-extension of quads, squat and rise, knee jerk, sensory front of leg

L5-dorsiflexsion of great toe and foot, walk on heels, lateral of leg

S1-plantar flexion of toe and foot, walking on toes, ankle jerk, back of leg

the neurologic examination should focus on ankle and great-toe dorsiflexion strength (the L5 nerve root), plantar flexion strength (S1), ankle and knee reflexes (S1 and L4), and dermatomal sensory loss. The L5 and S1 nerve roots are involved in approximately 95 percent of lumbar-disk herniations.

Rx

10 cc .5% Bupi c 1 cc (40 mg) solumedrol, use 1 ¼” 25 g needle to inject at dimple just adjacent to sacrum or at point of maximal tenderness

Flexeril and NSAIDs was no better than NSAIDs alone (Annals EM 41:6, p.818), if you want to use it, use 5 mg (Borenstein DG et al: Efficacy of a low-dose regimen of cyclobenzaprine hydrochloride in acute skeletal muscle spasm: results of two placebo-controlled trials. Clin Ther 25:1056, 2003);

Cochrane review showed small benefit but may be overwhelmed by side effects (MUSCLE RELAXANTS FOR NONSPECIFIC LOW BACK PAIN: A SYSTEMATIC REVIEW WITHIN THE FRAMEWORK OF THE COCHRANE COLLABORATION van Tulder, M.W., et al, Spine 28(17):1978, September 2003)
 

Ankylosing spondylitis is another important, though uncommon disease that presents with back pain. This inflammatory process usually affects young males and presents with slowly progressive back ache and stiffness that is worse in the morning and improves over the course of the day. Gradually, these patients develop diminished range of motion of the back. This is one of the HLA-B27-related inflammatory arthropathies that include psoriatic, Reiter’s, and inflammatory bowel disease-related syndromes. Physical examination reveals diminished excursion of the lumbar spine and chest. This is one situation in which plain films and the erythrocyte sedimentation rate (ESR) are helpful.

Spinal Epidural Abscess

review article (NEJM 2006;355(19):2012)

anterior associated with vertebral body osteo or acute discitis

posterior is often from hematogenous spread

blunt trauma can cause a hematoma which is a nidus for infection
 

risk factors include AIDS/HIV, DM, ETOH, IVDA, cancer, steroid use, renal failure

staph aureus is the cause in more than 50% of cases, then strep and enteric anaerobes/aerobes.  Actinomyces is a rare cause from dental sources.

Pain is the most common presentation along with fever and radicular symptoms.  The symptoms may develop over days to weeks.

Progression is normally spinal ache » radicular pain » limb weakness » paralysis

CBC, ESR (average is ~77 in SEA), Blood CX

Avoid LP

MRI is the 1st test of choice, though a combination of a CT and a myelogram should be reasonably sensitive.

CT c Contrast alone only detects 50% of cases.

Spinal Cord Compression

Get MRI spinals survey

Pt with bone metastases can get vertebral fractures with resulting compression even with a recent negative MRI

Dex 10 mg then 4 mg Q6

Soft Tissue Thoracic

Less acute than LS spine pain, but takes longer to resolve

Lumbrosacral

Lateral view through L4 sufficient as per study (see box)

Full series same dose of gonadal radiation as 6 yrs of daily C-XR

Get Films if <18, >50 or Trauma or >6 weeks duration or suspicion of occult cause

Causes:

Muscle

Sciatica

Cauda Equina-bowel/bladder incontinence or urinary retention/saddle anesthesia/decreased rectal tone

Spinal Stenosis-pain brought on by walking, relieved by rest but especially back flexion

Facet Arthopathy

Spondylolisthesis-slippage of 1 vetebrae over another

Fx-malignant or otherwise

Arthritis

Ankylosing Spondylitis-morning back pain relieved by exercise

Physical Exam

Most Disk problems are L5 (Foot Dorsi) or S1 (Plantar Flex)

Straight Leg Raise-If crossover sign seen, very specific

Standing-walk on toes for S1

Acetabular Rotation-have patient stand with arms at his side, rotate him 30 degrees either way, should not hurt as done by hip, not back

Axial Loading-should not hurt when you push down on top of head

Sitting-Foot Dorsi

Knee Reflex-L3 and L4

Lying-Hip Abduction(L5)

Prone-contract buttocks (L1)

Complete cord transection

Spinal shock refers to the loss of muscle tone and reflexes with complete cord syndrome during the acute phase of injury. The intensity of the spinal shock increases with the height of the level in the spinal cord.^[5] Spinal shock typically lasts less than 24 hours but has been reported occasionally to last days to weeks.^{[5] [6]} A marker of spinal shock is loss of the bulbocavernosus reflex, which is a normal cord-mediated reflex that may be preserved in complete cord lesions. The bulbocavernosus reflex involves involuntary reflex contraction of the anal sphincter in response to a squeeze of the glans penis or a tug on the Foley catheter. The termination of the spinal shock phase of injury is heralded by the return of the bulbocavernosus reflex; increased muscle tone and hyperreflexia follow later.

Central Cord

Most often caused by hyperextension injury, especially in older folks c degenerative disease

Bilat motor paresis with effects on upper>lower and distal>proximal.  May also feel burning sensation in upper extremities. (Burning hands syndrome)

Brown-Sequard

Hemisection of the cord, usually from penetrating trauma.  If from blunt, suspect fracture of lateral mass

Ipsilateral loss of motor and proprioception and contralateral heat/pain sensation loss

Anterior Cord

Loss of motor and pain/temp sensation with preservation of touch/proprioception

Hyperflexion inhuries are usually the etiology.  Needs immediate neurosurg consultation as prompt treatment has good results

Cauda Equina

The cauda equina (“horse’s tail”) is the name given to the lumbar and sacral nerve roots that continue on within the dural sac caudal to the conus medullaris. The etiology of the cauda equina syndrome is usually a ruptured, midline intervertebral disk, most commonly occurring at the L4-L5 level. Tumors and other compressive masses may cause the syndrome as well. Like the conus medullaris syndrome, patients generally present with progressive symptoms of fecal or urinary incontinence, impotence, distal motor weakness, and sensory loss in a saddle distribution. Muscle stretch reflexes may also be reduced. The presence of urinary retention is the single most consistent finding, with a sensitivity of 90%.^[19] Low back pain may or may not be present.

Give DEX 16-96 mg divided Q6

A Babinski reflex suggests involvement of the conus medullaris, the lower part of the spinal cord which is in proximity to the nerve roots. Thus, injuries to this area often yield both upper and lower motor neuron signs (JEM, 11/06, pg. 381).

Spinal Subarachnoid Hemorrhage

usually from AVMs

Syringomyelia

The classic pattern of sensory deficit is a loss of pain and temperature sensation in the upper extremities, with preservation of proprioception and light touch. This phenomenon is described as a “disassociative anesthesia” because of the discrepant loss of sensory modalities. The sensory deficit is often described as being in a “cape-like” distribution over the shoulders and arms. The anatomic basis for the neurologic findings of syrinx is due to its central location near the central canal. Here it may compress the crossing fibers of the lateral spinothalamic tract that carry pain and temperature fibers. Crude touch, position, and vibratory sensation are typically unaffected. Sensory fibers from the lower limbs are similarly spared.

Spinal Epidural Hematoma

Preventing and Treating LBP

FIRST and FOREMOST: if you know you are going to be exerting an untoward amount, such as bicycling for a long way the first time in months, shoveling snow, working in the yard, or any other "burst" work (including weekend warrior sports) take a good, solid dose of the NSAID that works best for you. Absent personal knowledge of the "best one" here are my suggestions:

ASA: 975 mg p.o. before and after the exercise (doses at least 4 hours apart).

or:

Ketorolac: 20 mg p.o. before exercise and a second dose before retiring if any pain is felt.

or:

Ibuprofen: 750 mg  p.o. before and after the exercise (doses at least 4 hours apart).

You can substitute an appropriate (upper end) dose of any other NSAID (except APAP) which works well for you without side effects. Indomethacin; 50 mg p.o. works bet for me.

IF YOU MISS PROPHYLAXIS: *immediately* take a dose of NSAID and lay down, and if possible, take a nap. If you do this before the pain starts or when it just twingeing it is almost as effective as prophylaxis

Prophylaxis with NSAIDs before injury is incredibly protective. I learned this doing cerebral ischemia experiments and decided to try it on myself before running a marathon. Worked beautifully; works for brains and works for muscles! Furthermore, it has worked very well for me and everyone I've suggested it to since. If you would normally be crippled with stiffness and pain you will have either no pain or only a trivial amount. ASA seems to be the best for this (alas, I can't take it).

Once you are injured and hurting you have a much more difficult problem. I have answers for this too, but some are risky to the point of being potentially deadly. Still, in some situations the risks were worth it to me:

Probably the best (safest) way to knock down post-injury muscoloskeletal pain is IM ketorolac; 20-30 mg.

If you are willing to risk avascular necrosis for the head of the femur then add 30 mg of p.o. prednisone to the ketorolac.

AND THE MOST EFFECTIVE (AND MOST RISKY METHOD): butazoladine; 200-400 mg, p.o. Butazoladine is the absolute Cadillac of NSAIDs IMHO. It really works. The downside is, of course, perhaps a 1 in 250,000 chance of developing lethal agranulocytosis. I've used but a few times when others' lives depended upon my being able to perform. It is incredibly effective. I still marvel that it is sold by Ceiba-Geigy OTC in Mexico and many other 3rd world countries.

In FL's case, IM ketorolac plus several soaks a day in a hot tub should do the trick. Avoid babes in the tub; you need to RELAX and soak .

Mike Darwin
 

With Methocarbamol, however, you have to give it in proper dosage. You
build a blood level and maintain it; "prn" treatment does not work. In the
average-sized adult, it takes 1.5 gm. q 6 h (6 grams a day); NOT prn. I give
my patients a 10-day supply and tell them to take it whether or not the
symptoms improve. If they do not improve after a week, they can stop the
drug