Low Back Pain Brad Bunney, MD Department of Emergency Medicine University of Illinois College of Medicine Chicago, ILSlide 2
Objectives Discuss the diverse sorts of back torment Review anatomical standards Review nontraumatic etiologies for intense back agony with neurological discoveries Treatment choices for patients with back torment and neurological discoveriesSlide 3
The Case 55 yo male with low back torment. The torment is sharp, right-sided, more awful with development and non-transmitting. He has no shortcoming, deadness or incontinence. No hx of injury. Pmhx: HTN, peevish gut disorder, cervical plate herniation Meds: none Sochx: liquor use PE: afebrile, VSS Back: mellow delicacy right paraspinal zone, L2-3 Neuro: typical What would you like to do?Slide 4
The Case He is given valium which improves him and is sent home. after 5 days he is at another doctor\'s facility with the objection of back torment, says it is the same as some time recently, "I came up short on my Valium". PE: Afebrile, VSS Back: right paraspinal delicacy, more awful with development Neuro: ordinary What would you like to do?Slide 5
The Case He has a stomach CT sweep to R/O renal stone which was ordinary. He is given an injection of Torodol which improves him feel and is released with Motrin and Valium. He returns 2 days after the fact with exacerbating agony that transmits to the right foot and left knee. He has deadness to the thighs and crotch, and has been incontinent of stool. PE: Afebrile, VSS Back: diffuse delicacy to lumbar spine palpation Neuro: RLE-3/5 quality, deadness front and med thigh, diminished reflex. LLE-4/5 quality. What would you like to do?Slide 6
Epidemiology 60-90% experience back torment in lifetime 5 million handicapped No complete analyses in 80% 90% show signs of improvement regardless of treatmentSlide 7
Anatomy Vertebra – body, neural curve, hard process Ligaments & muscles = dependability Cervical nerve roots go above body All others go underneathSlide 8
Types of Back Pain Local Referred RadicularSlide 9
Types of Back Pain Local Irritation of bone, muscle, joints Steady, sharp or dull Worse with developmentSlide 10
Types of Back Pain Referred Non-spinal alluded to back - Abdominal aortic aneurysm Originate in spine however felt somewhere else - Upper lumbar torment felt in upper thighs Rarely reaches out beneath the kneeSlide 11
Types of Back Pain Radicular Irritation of the nerve root Can transmit to the calf and feet Worse with development that builds CSF weightSlide 12
Nerve Root Diagnosis L4 Pain = sidelong back, antero-horizontal thigh, front calf Numbness = foremost thigh Weakness = quadriceps Diminished automatic Squat and riseSlide 13
Nerve Root Diagnosis L5 Pain = hip, crotch, postero-parallel thigh, sidelong calf and dorsum of foot Numbness = parallel calf Weakness = dorsiflex awesome toe Heel strollingSlide 14
Nerve Root Diagnosis S1 Pain = mid-gluteal district, back thigh, back calf to heel & sole Numbness = back calf Weakness = plantar flex extraordinary toe Diminished lower leg jerk Walk on toesSlide 15
Spinal Cord Compression Malignant epidural spinal rope pressure (MESCC) Disk herniation Spinal epidural canker (SEA) Spinal epidural hematoma (SEH)Slide 16
Spinal Cord Compression Factors Force of pressure Direction of pressure Rate of pressureSlide 17
MESCC Hematogenous spread Bone marrow Compress rope and vascular supply Edema, dead tissueSlide 18
MESCC Prostate Lung Breast Non-Hodgkin\'s lymphoma Multiple myeloma Renal cell diseaseSlide 19
MESCC Initial presentation in 20% of malignancies Cervical, thoracic & lumbar by extent of vertebral body volume Thoracic is most regularSlide 20
MESCC 95% have back torment Precedes different side effects by 1-2 months Percussion inclinations, thoracic area, more awful restingSlide 21
MESCC 75% have shortcoming by time of analysis Weakness symmetric Ascending deadness Autonomic brokenness, urinary maintenanceSlide 22
MESCC Plain X-beam 10-17% false negative 30-half of bone must be annihilated for X-beam to be certain MRI, CT myelography are measuresSlide 23
MESCC Corticosteroids first line for edema Dexamethosone, 20-100 mg load, 4-24 mg 4 times/day Radiation treatment inside 24 hoursSlide 24
MESCC Surgery for: inert to radiation treatment Acute neurological weakenings Chemotherapy – Non-Hodgkin\'s lymphomaSlide 25
Disk Herniation L4-5, L5-S1 most basic Cervical and thoracic do happen Thoracic: unexpected neuro shortages Narrow trench Postero-sidelong part of the plateSlide 26
Disk Herniation Not important to have history of strain or damage Unilateral radicular back torment with nerve root impingementSlide 27
Disk Herniation X-beam just great if between vertebral circle is tight MRI is best quality level Electromyelography confines the particular nerve rootSlide 28
Disk Herniation Initial treatment is to lessening weight on the root Bed rest up to 4 weeks Non-steroid mitigating Muscle relaxantsSlide 29
Disk Herniation Absolute sign for surgery Significant muscle shortcoming Progressive neurological shortfall with bed rest Bowel or bladder brokennessSlide 30
Disk Herniation Relative sign for surgery Pain notwithstanding bed rest Recurrent scenes of serious tormentSlide 31
SEA Risk Factor IVDA Diabetes Trauma Prior spinal surgery or nerve pieces Immune bargained hostSlide 32
SEA Presenting Complaints Back agony Paresthesias Motor deficiencies FeverSlide 33
SEA Diagnosis WBC Sedimentation Rate MRI = highest quality levelSlide 34
SEA Organisms Staphylococcus aureus - Methicillin safe – 15% Streptococcus Escherichia coli Pseudomonas Klebsiella Mycobacterium TuberculosisSlide 35
SEA Treatment Surgery – relying upon seriousness of neuro shortages Extent of spine included Infecting life form AntibioticsSlide 36
SEA Non-Operative Indications Panspinal association Lumbosacral SEA and ordinary neuro exam Fixed neuro deficiency for > 48 hoursSlide 37
SEA Antibiotics Start promptly Vancomycin Aminoglycoside or 3 rd era cephalosporin 4 to 6 weeksSlide 38
Spinal Epidural Hematoma (SEH) Risk Factors Coagulapathy Trauma Vascular sore Surgery Epidural catheterizationSlide 39
SEH Diagnosis Back torment, neuro shortfall Symptom onset to max. neuro shortage = 13 hours All fragments of spinal line MRI = highest quality level Plain X-beam or CT filter for cracks or disengagementSlide 40
SEH Treatment Surgical departure Immediate surgery inside 12 hours of presentation would be advised to result than later surgerySlide 41
The Case MRI is done which affirms a compressive injury from L2 to L4. WBC = 18,000. The patient is given anti-microbials and is admitted to neurosurgery. A L3-L4 laminectomy is done and discharge is depleted. Organism= Streptococcus and Stomatococcus mucilaginosis Patient was released to a recovery office on healing facility day 13 for 6 weeks of Vancomycin treatment. At the season of release he was landmass, yet could just ambulate with helped utilization of a walker.Slide 42
Conclusion Back agony is basic in the ED Radicular torment obliges persistence to discover the cause The seriousness of spinal rope pressure is identified with power, term and rate Emergent treatment is essential "Spinal Cord Attack"Slide 43
First line of treatment for epidural spinal rope pressure from metastatic malignancy is: A. Radiation treatment B. Surgery C. Corticosteroids D. ChemotherapySlide 44
The most well-known site of epidural spinal string pressure from metastatic growth is: A. Cervical spine B. Thoracic spine C. Lumbar spine D. Sacral spineSlide 45
All of the accompanying are signs for non-agent treatment of spinal epidural abscesses aside from: A. Pan-spinal association B. Lumbosacral SEA and typical neurological exam C. Fixed neurological deficiencies for more than 48 hrs D. Urinary incontinence and tangible shortfallSlide 46
All of the accompanying add to the seriousness of spinal line pressure aside from: A. Force of pressure B. Length of spinal line compacted C. Duration of pressure D. Rate of pressureSlide 47
The most widely recognized life form refined in spinal epidural abscesses is: A. Streptococcus B. Pseudomonas C. Staphylococcus aureus D. Klebsiella E. Mycobacterium tuberculosis
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