Back Pain Case

[GiJoe]

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So I had a 33 yo guy, hx of lumbar disc herniation x 2 -3 months that was causing a 50 % canal stenosis. he said he was doing better but yesterday, while walking, suddenly developed worsening pain radiating down his leg---just like he had before 2 months ago.

no change in bowel or bladder, no saddle anesthesia. some weakness in the left leg, prob sec to pain but he could feel his extremities.

on exam, the guy was in pain, he couldnt walk. but had normal rectal tone, normal perianal sensation. normal anal wink. left leg, slightly weaker than the right, prob secondary to pain.

post void residual was 20 ml

got 4 mg dilaudid iv and 30 toradol -- still no relief.


who would order and Emergent MRI from the ED?

 

[Apollyon]

I would. Confirmed history with an acute presentation, even though the horse isn't out of the barn yet, gets the MRI, and, likely, a call to NSx. You don't wait for the house to burn down before you try and put out the fire.

 

[annie5644]

this is a great question that i have wondered about many times. because it happens ALL the time and i always leave feeling ambiguity about what should be done in the ED. frank cauda equina sx = easy answer = MRI/spine c/s. bull**** msk back pain = easy = PCP f/u, motrin, valium etc. the truly miserable disk herniations are tough though.

in my experience, while pain control is acutely an issue, the spine docs never want to urgently intervene or even admit the pt unless there is frank weakness. so personally, i don't get the MRI unless they have true weakness or cauda sx. what are other's practices?

 

[Rendar5]

4mg dilaudid IV and he wasn't knocked out? Damn poor guy is really tolerant 🙁

 

[GiJoe]

if this patient felt much better after 4mg of dilaudid and demonstrated improved range of motion and could take a few steps......(AND no exam findings suggestive of acute cauda equina )does that pretty much exclude the need for an emergent MRI and safe discharge?

annie5644, i'm totally with you on this one. I hate patients like this. I would love to hear what some of the more experienced folks out there in their practice deal with this type of dilemma.

 

[ERNerd]

I haven't seen a situation quite like this yet, as I just recently finished residency and started at a rural hospital. My hospital doesn't have it's own MRI machine, and I mostly work nights. My options:

1) CT (of little utility in this case, I think)

2) Transfer an hour or more away to a facility with NSx. I've been on the receiving end of this transfer and it's painful. ED doesn't want patient boarding while awaiting MRI, and NSx doesn't even want to look at the patient until the test is done. Fewer than 1 in 5 actually get admitted to NSx, at least where I trained.

3) Attempt to admit to Medicine for non-emergent MRI the next day (likely a tough sell, and for good reason, without a spine surgeon to act on the results of the study)

4) Discharge with urgent referral for MRI and NSx (but difficult to get things arranged in the middle of the night)

I guess the best option from a med-mal perspective (and from the patient's perspective too, on the outside chance that acute intervention is warranted) is #2, but none of the options are very attractive.

 

[Hamhock]

So I had a 33 yo guy, hx of lumbar disc herniation x 2 -3 months that was causing a 50 % canal stenosis. he said he was doing better but yesterday, while walking, suddenly developed worsening pain radiating down his leg---just like he had before 2 months ago.

no change in bowel or bladder, no saddle anesthesia. some weakness in the left leg, prob sec to pain but he could feel his extremities.

on exam, the guy was in pain, he couldnt walk. but had normal rectal tone, normal perianal sensation. normal anal wink. left leg, slightly weaker than the right, prob secondary to pain.

post void residual was 20 ml

got 4 mg dilaudid iv and 30 toradol -- still no relief.


who would order and Emergent MRI from the ED?

no cauda, so no need for emergent MRI (if at fancy uni with 24h MRI-easy access, then fine)

but 4mg IV dilaudid and NO relief - admit for pain control (sadly, to medicine)...can get MRI in morning/daytime hours

humble and simple HH

 

[kungfufishing]

I would probably get the MRI in light of the known prior disease and objective weakness.

 

[Apollyon]

I would probably get the MRI in light of the known prior disease and objective weakness.

We may be the most senior people on here, with one unknown exception (Annie1234), and I wonder if we're speaking from experience (where "experience comes from good judgment, and good judgment comes from bad judgment"), but I always think of the woman I saw 1 yr out, who'd gotten the bum's rush from another hospital in town, who had, as per the NSx, "the biggest disc herniation I'd seen since I was a resident" (and that was >10 years ago). Seeing a frank cauda equina is rare (the young lady of whom I speak was one), and being in practice is seeing how close you are to teetering on the edge. God forbid you be the last hombre with your name on the chart if you D/C this guy and he comes back in - literally - crapping the bed.

 

[po' boy]

no cauda, so no need for emergent MRI (if at fancy uni with 24h MRI-easy access, then fine)

but 4mg IV dilaudid and NO relief - admit for pain control (sadly, to medicine)...can get MRI in morning/daytime hours

humble and simple HH

I'm with Hamhock. I'd call NSG to request a consult on this patient but if you can't walk, you can't go home -- best to have the hospitalists admit to deal with the pain issues and complete the MRI workup (which takes several hours where I am, especially at night) and tell them you've already contacted Neurosurgery, who approves the plan. I always have to argue with the lazy MRI tech to come in, even in possible NSG emergencies like this one, and it takes time.

 

[GiJoe]

what about a positive response to pain meds? would that pretty much exclude the need for an emergent MRI and safe discharge?

 

[kungfufishing]

Funny how no matter how many times someone tells you something, screwing up once teaches you far more.

 

[GiJoe]

So I had a 33 yo guy, hx of lumbar disc herniation x 2 -3 months that was causing a 50 % canal stenosis. he said he was doing better but yesterday, while walking, suddenly developed worsening pain radiating down his leg---just like he had before 2 months ago.

no change in bowel or bladder, no saddle anesthesia. some weakness in the left leg, prob sec to pain but he could feel his extremities.

on exam, the guy was in pain, he couldnt walk. but had normal rectal tone, normal perianal sensation. normal anal wink. left leg, slightly weaker than the right, prob secondary to pain.

post void residual was 20 ml

got 4 mg dilaudid iv and 30 toradol -- still no relief.


who would order and Emergent MRI from the ED?

so what ended up happening was I admitted the guy for pain control. I was following what happened to him and he ended up getting another MRI ( i think the same day)which looked worse and ended up going to the OR. I can't tell if it was emergent or anything bc they're still do paper charts upstairs, but it got me thinking, did I miss and acute spinal cord compression?


thanks for the responses.

 

[BADMD]

So I had a 33 yo guy...

Had a similar presentation of a guy a few months ago. I figure it is just pain and effort related weakness. Treat the pain with NSAID and opiates (improved from 8 to 3) and the dude still can't stand without assistance.

I get a NS consult an MRI and sign the guy out. Read the follow up dictation the next day as something to the effect of "Cleared by NS. Needs to report to PT in the AM for rehab." 12 hours later I get an urgent page from radiology. They read his MRI as "Mass, likely menigioma with significant compression of the Cauda equina. Non-contrast study limits evaluation. Recommend emergent Contrast MRI."

I can't find the guy at any of the numbers listed for him and start having horrible visions of this guy in some hallway, on the floor, unable to walk, incontinent and cursing my name while struggling to reach a phone with Jeffery Feiger on speed dial. I pass the case off to the person responsible for finding lost patients. The guy shows up 2 days later. Emergent contrast MRI is basically read as "Oops, our bad. We don't see anything." Back pain is still unchanged and his walking isn't much better.

The moral of the story? Hell if I know. I'm not sure you can win with back pain.

 

[docB]

no cauda, so no need for emergent MRI (if at fancy uni with 24h MRI-easy access, then fine)

but 4mg IV dilaudid and NO relief - admit for pain control (sadly, to medicine)...can get MRI in morning/daytime hours

humble and simple HH

I agree with this. I'd like to get an MRI for it but my hospitals have a policy against getting any MRI in the ED unless we have criteria for an acute cord syndrome. Granted if we're really worried we might... how to put this?... overstate some of the symptoms but calling in an MRI tech is very expensive and it gets a lot of scrutiny and it gets billed to the patient so we don't do it unless we're really worried.

what about a positive response to pain meds? would that pretty much exclude the need for an emergent MRI and safe discharge?

I don't think that would make too much of a difference for me. I can get anybody's pain under control. Remember that in Vegas we pioneered the use of propofol for insomnia and chronic pain. But the pathology is still there.

So it does seem that getting MRIs is relatively difficult in most EDs. We can't just check a box like we can for CT. Is that a good thing. I know that I see several people a week who come in demanding MRI for their chronic back or knee pain. Should we be doing it for them?

 

[GiJoe]

docB,

if the guy could walk with pain meds, doesnt that exclude the possibility of acute compression then? I would think if ur cord is squeezed, even a 100 mg of dilaudid wouldn't fix it

 

[dchristismi]

Methinks 100mg of dilaudid would "fix" it in a slightly different way.

Tough case. We also can't get emergent MRI at night without a damn good reason, and don't have NSG.

 

[Dwindlin]

Methinks 100mg of dilaudid would "fix" it in a slightly different way.

I don't know why but I found this really funny.

 

[docB]

docB,

if the guy could walk with pain meds, doesnt that exclude the possibility of acute compression then? I would think if ur cord is squeezed, even a 100 mg of dilaudid wouldn't fix it

You're right. I didn't say that well. I meant I'd go off the exam in terms of rectal tone, perineal anesthesia and so on more than the degree of pain.