otacon88

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Ah the all dreaded back pain. Something that seems so simple, yet so far, far from it. How do you guys differentiate the serious pathology from the benign ones? Yes we all know the red flag symptoms - bowel/bladder incontinence, neuro deficits, IVDA + fever, saddle anesthesia, poor rectal tone, etc etc, but how do you REALLY tell the difference; say someone can't lift their left leg up - is it because they have a neuro deficit in that left leg or is it because of the immense pain they're having in that lumbar region that they're unwilling to lift that leg up?

Let me present a case to you guys:

I had a 58 year old female come in the other week for back pain. Started 3 days prior to arrival in the ED, complaining mainly of left lower paraspinal pain, shot down to the back of her leg. States it was mainly pain, didn't feel any weakness/numbness/tingling. States was moving boxes around and thinks might have hurt her back that way. Was having increased difficulty walking because of the pain, had taken some ibuprofen/tylenol which helped her pain and was able to ambulate more readily after meds. She had no PMH, took no meds, no red flag symptoms. Physical exam - tenderness over left and right paraspinal lumbar muscles, no midline spinal tenderness, straight leg test negative but did elicit pain in the left lower paraspinal region, had difficulty lifting her left leg up against gravity but kept saying it was because of the pain in the back and not because she felt weak, was able to stand and ambulate, had full strength and sensation in her ankle and toes. Gave her pain relief meds in the ER, shot xray's of her back, everything checked out, she felt a lot better, could walk without difficulty, and d/c home.

She came back a week later, MR showed cord compression on the left side.

I keep going over the case in my head and I don't see how I would have done anything differently everytime. Unless my entire approach is incorrect. What would you guys have done?
 

VA Hopeful Dr

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I don't see anything wrong with what you did. You actually did more than I usually do in those situations. This is a perfect example of the "If you're not getting better in 2-3 days, f/u with PCP" instructions that I give literally everyone that walks in my door.
 
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Birdstrike

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Cord compression at what level, and from what? I'm going to presume it's a malignancy (age > 50 is a risk factor for back pain from malignancy, much lower threshold to image) likely at the thoracic level (since there's not much cord in the L spine, only L1, for the most part).

Age > 50, have a much lower threshold to image. Even if it's just a ct abd/pelvis with stone protocol, you've still got a shot at seeing a malignancy if it's bad enough to eat up spine, heading towards cord compression (as well as a AAA). Choosing to get an MRI acutely is a much tougher call, since the indication is usually a hard Neuro sign, and once you've got a hard Neuro sign, often times there's irreversible damage from a cord compression. Cord compressions are tough for that reason, in that eveyone is going to tell you your MRI order is bull****, until there are hard Neuro signs that are too advanced to fully reverse. Then, by the time they agree it's needed, you're the one getting the blame.

This is also why defensive-medicine reduction policies are bullsh¡t. Does Choosing Wisely cover your arshnickle or the authors rush to your defense when you miss a cord compression?

F- no.

Choosing Wisely will not have your back when you miss a cord compression trying to fix a health care system you didn't break. Neither will any other of these cost reducing fools, who aren't liable for patient outcomes. In fact, don't be surprised if some of those people whose guidelines and textbooks you follow, show up to testify against you, for following their exact guidelines and texts:

http://www.epmonthly.com/features/current-features/gross-negligence-a-slippery-slope-for-dubious-expert-testimony/

Order tests and order them liberally, and without remorse.
 
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TimesNewRoman

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Cord compression at what level, and from what? I'm going to presume it's a malignancy (age > 50 is a risk factor for back pain from malignancy, much lower threshold to image) likely at the thoracic level (since there's not much cord in the L spine, only L1, for the most part).

Age > 50, have a much lower threshold to image. Even if it's just a ct abd/pelvis with stone protocol, you've still got a shot at seeing a malignancy if it's bad enough to eat up spine, heading towards cord compression (as well as a AAA). Choosing to get an MRI acutely is a much tougher call, since the indication is usually a hard Neuro sign, and once you've got a hard Neuro sign, often times there's irreversible damage from a cord compression. Cord compressions are tough for that reason, in that eveyone is going to tell you your MRI order is bull****, until there are hard Neuro signs that are too advanced to fully reverse. Then, by the time they agree it's needed, you're the one getting the blame.

This is also why defensive-medicine reduction policies are bullsh¡t. Does Choosing Wisely cover your arshnickle or the authors rush to your defense when you miss a cord compression?

F- no.

Choosing Wisely will not have your back when you miss a cord compression trying to fix a health care system you didn't break. Neither will any other of these cost reducing fools, who aren't liable for patient outcomes. In fact, don't be surprised if some of those people whose guidelines and textbooks you follow, show up to testify against you, for following their exact guidelines and texts:

http://www.epmonthly.com/features/current-features/gross-negligence-a-slippery-slope-for-dubious-expert-testimony/

Order tests and order them liberally, and without remorse.
I remembering listening to a podcast (don't remember which one) saying if you're worried about bony mets you need to image E-spine because it's not uncommon to have more than one bony met when you have one and you can, not uncommonly, have falsely localizing neuro findings. Thoughts?
 

Birdstrike

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I remembering listening to a podcast (don't remember which one) saying if you're worried about bony mets you need to image E-spine because it's not uncommon to have more than one bony met when you have one and you can, not uncommonly, have falsely localizing neuro findings. Thoughts?
I assume you mean "T" spine, not "E." But, that's right. Thoracic is most common, by far.

"About 70% of symptomatic lesions are found in the thoracic region of the spine, particularly at the level of T4-T7. Of the remainder, 20% are found in the lumbar region and 10% are found in the cervical spine. More than 50% of patients with spinal metastasis have several levels of involvement. "

http://emedicine.medscape.com/article/1157987-overview#2
 

TimesNewRoman

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I assume you mean "T" spine, not "E." But, that's right. Thoracic is most common, by far.

"About 70% of symptomatic lesions are found in the thoracic region of the spine, particularly at the level of T4-T7. Of the remainder, 20% are found in the lumbar region and 10% are found in the cervical spine. More than 50% of patients with spinal metastasis have several levels of involvement. "

http://emedicine.medscape.com/article/1157987-overview#2
I meant E. We call E-spine entire-spine. Is that not a thing?
 
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otacon88

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But the patient in the scenario had absolutely no medical history (was a pt who regularly followed up with her PCP) - is age alone justification to order CT/MR for every pt >50 coming in with back pain? And what if it's cord compression from disc herniation and pt had no idea about it and we opted to get CT and missed the cord compression - how do we know what test to order (CT vs MR) and when? It's easy in patients we have a medical hx on and can guide us towards which path to take, but in the completely undifferentiated patient with no medical history makes it a little harder.

And Birdstrike - yes you are spot on, the pt had a paraspinal mass causing cord compression at the level of T11.
 

Arcan57

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OP, you were completely justified in sending patient home. While I think in Strike's new job the standard of care probably is to MRI pretty much everybody referred to him, you'll MRI the next 100 50+ yr old back pains without neuro findings presenting to the ED and not pick up a single case of cord compression. You have to do a good neuro exam (not sufficient to say moving all 4 ext and ambulating without difficulty) but if their sensation, motor, and reflex exam is normal and they have no midline ttp then in the absence of known malignancy there is no indication for an MRI in the ED (unless you're hunting down epidural abscess in patient with risk factors).
 

TooMuchResearch

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Cord compression at what level, and from what? I'm going to presume it's a malignancy (age > 50 is a risk factor for back pain from malignancy, much lower threshold to image) likely at the thoracic level (since there's not much cord in the L spine, only L1, for the most part).

Age > 50, have a much lower threshold to image. Even if it's just a ct abd/pelvis with stone protocol, you've still got a shot at seeing a malignancy if it's bad enough to eat up spine, heading towards cord compression (as well as a AAA). Choosing to get an MRI acutely is a much tougher call, since the indication is usually a hard Neuro sign, and once you've got a hard Neuro sign, often times there's irreversible damage from a cord compression. Cord compressions are tough for that reason, in that eveyone is going to tell you your MRI order is bull****, until there are hard Neuro signs that are too advanced to fully reverse. Then, by the time they agree it's needed, you're the one getting the blame.

This is also why defensive-medicine reduction policies are bullsh¡t. Does Choosing Wisely cover your arshnickle or the authors rush to your defense when you miss a cord compression?

F- no.

Choosing Wisely will not have your back when you miss a cord compression trying to fix a health care system you didn't break. Neither will any other of these cost reducing fools, who aren't liable for patient outcomes. In fact, don't be surprised if some of those people whose guidelines and textbooks you follow, show up to testify against you, for following their exact guidelines and texts:

http://www.epmonthly.com/features/current-features/gross-negligence-a-slippery-slope-for-dubious-expert-testimony/

Order tests and order them liberally, and without remorse.
I don't recall any choosing wisely about not ordering MRI for suspected back badness.
 

dotcb

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You're only responsible to provide reasonable care that another emergency physician might provide. What you did was reasonable, and I probably would have done the same. I sent someone home without imaging yesterday who had an even more concerning presentation, without imaging, because I thought about it long & hard, and I thought MRI would be low yield. I emailed her PMD, gave her an analgesic, and wrote a good note.

You're going to miss stuff. It's going to happen. Patients are going to bounce back who you sent home. You need to be OK with it.

Society needs to make up its mind - whether we accept ridiculous amounts of overtesting or we accept that occasionally things are missed. I have a real problem with #1, and I try to use my judgement to provide what seems reasonable to me. I consider risk, write notes, and am comfortable with some uncertainty.
 

Birdstrike

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OP, you were completely justified in sending patient home. While I think in Strike's new job the standard of care probably is to MRI pretty much everybody referred to him, you'll MRI the next 100 50+ yr old back pains without neuro findings presenting to the ED and not pick up a single case of cord compression. You have to do a good neuro exam (not sufficient to say moving all 4 ext and ambulating without difficulty) but if their sensation, motor, and reflex exam is normal and they have no midline ttp then in the absence of known malignancy there is no indication for an MRI in the ED (unless you're hunting down epidural abscess in patient with risk factors).
Did you really just try to put me into the "Specialist who doesn't get what it's like in the ED" box? Nice try. Lol.

I didn't tell him to MRI everyone with back pain. Read what I wrote. I didn't tell him he did anything wrong either. In fact, I alluded to the fact of how hard is it to pick up a spinal cord compression until it's too late. Most acute spinal cord compressions are picked up only after there's irreversible cord damage. That's the norm, unfortunately, for the reasons you state.

This is a very broad subject and a good one for a thread. My response to him was Emergency Medicine specific and will continue to be. "Imaging" or working up back pain with a red flag (extremes of age, CA history or signs like weight loss, fever, aaa risk factor, Neuro signs) could mean lots of things. Of course if you have myelopathic signs, get your MRI. By that time it's an easy sell, but also too late.

For bone mets a lot of times that can be picked up on a thoracic plain film series in the ED. I've picked that up before, as you likely have. That's a cord compression prevented and saved and someone else can get the MRI later. Also, vertebral compression fractures can be screened for on plain films in that age group and you might see a bone met causing a pathologal fracture. Also, a stone protocol ct (which I mentioned) is immensely easier to get in the ED and though not 100% sensitive for things like AAA, abscesses, or bone mets, a lot of times it may still pick those things up, or at least give a clue that further imaging is needed. I've picked up missed retro peritoneal mets on CT, also, that presented as blown off back pain, all in the ED.

The same goes for unexplained back pain in kids. It's unusual and in and of it's self often a red flag. Does that mean you MRI every kid with back pain in the ED? No. In fact, you're more likely to need to check for a uti or pyelo. I've picked up stones in kids < 10. It's not every day but it happens. Also, torsion with back/flank pain.

I know you know all this, but my point is, that I did not say or imply "MRI every back pain in the ED." You're twisting the point of my post around. I do think you should have a low threshold for some appropriate additional work up in the ED when there's red flags, and do not let the Utopian save-the-healthcare-system mantras for cost reduction get too much into your head, because no one, NO ONE that's published any of those cost containing guidelines or textbooks will stand by any of us when there's been a bad outcome, whether you followed their guidelines or not. It's my opinion that they're more likely to take cash to testify against you; see Rosen and Gabaeff.

http://www.epmonthly.com/features/current-features/gross-negligence-a-slippery-slope-for-dubious-expert-testimony/

(A good summary for students, regarding back pain "red flags," though I think their age >70 should be lower, and often is listed as low as 50: http://www.acepnow.com/article/high-value-diagnostic-approach-low-back-pain/)
 
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gutonc

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I remembering listening to a podcast (don't remember which one) saying if you're worried about bony mets you need to image E-spine because it's not uncommon to have more than one bony met when you have one and you can, not uncommonly, have falsely localizing neuro findings. Thoughts?
I agree that this is appropriate management when spinal (bony, dural, whatever) mets are found, but I don't think you guys need to be doing it in the ED, that's what Onc, Rad Onc and Neurosurg are for. And if you ever want to see an MRI tech go postal, ask for an urgent CTL MRI without another exam or imaging finding to back it up.

FWIW, I think you did the right thing. Hell, I'm an oncologist and if I MRId the total spine of every one of my 50+yo patients with back pain I'd have to buy my own MRI machine (and would still have a low catch rate).
 

TimesNewRoman

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I agree that this is appropriate management when spinal (bony, dural, whatever) mets are found, but I don't think you guys need to be doing it in the ED, that's what Onc, Rad Onc and Neurosurg are for. And if you ever want to see an MRI tech go postal, ask for an urgent CTL MRI without another exam or imaging finding to back it up.

FWIW, I think you did the right thing. Hell, I'm an oncologist and if I MRId the total spine of every one of my 50+yo patients with back pain I'd have to buy my own MRI machine (and would still have a low catch rate).
Sorry, I guess I didn't make my point clear. The argument was to image the entire spine in cancer patients with neuro findings. The argument was that T spine mets are more common than L spine mets and it's not horribly uncommon for cord compression to "falsely localize."

And the MRI machine is so far from the ED, the tech would get burned out well before me made it to the ED.
 

Birdstrike

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But the patient in the scenario had absolutely no medical history (was a pt who regularly followed up with her PCP) - is age alone justification to order CT/MR for every pt >50 coming in with back pain? And what if it's cord compression from disc herniation and pt had no idea about it and we opted to get CT and missed the cord compression - how do we know what test to order (CT vs MR) and when? It's easy in patients we have a medical hx on and can guide us towards which path to take, but in the completely undifferentiated patient with no medical history makes it a little harder.

And Birdstrike - yes you are spot on, the pt had a paraspinal mass causing cord compression at the level of T11.
1- I'm not saying you did anything wrong.

2-Is age alone a red flag for further work up? In a lot of cases yes. If they've had back pain for 20 years, there's no red flags and they had an MRI 3 wk ago and nothing's changed since then, maybe not. But is it terrible to put an ultrasound on someone's aorta if they have new back pain, and they're >50? No. It it a terrible idea to ct some of these looking for a stone, knowing you might pick up some cancers and AAAs in this age group? No. Is it a terrible idea to do plain films on some of these, knowing that as a rule lots of them have declining bone density and can have compression fractures with minimal or no trauma, and also are in an age group where you may pick up bone mets as a first sign of breast or prostrate ca? No. Do you have to MRI everyone? Of course not.

3-Acute cord compression from a thoracic disc is pretty rare. Cervical discs causing canal stenosis that can affect the cord are common. Lumbar discs are common but won't affect the cord (unless conus syndrome, which mimics cauda equina, with upper cns signs) or will affect nerve roots giving cauda equina itself.

I'm not saying any of this changes anything with your patient, that you messed up, or that I would have done anything different. And I don't know what level you're at either, but if your a resident, take this cost containment stuff with a grain of salt because it only increases your liability and there will be very little if any reward from following it, other than maybe a lower length of stay metric in your patients.
 

Birdstrike

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Sorry, I guess I didn't make my point clear. The argument was to image the entire spine in cancer patients with neuro findings. The argument was that T spine mets are more common than L spine mets and it's not horribly uncommon for cord compression to "falsely localize."

And the MRI machine is so far from the ED, the tech would get burned out well before me made it to the ED.
I agree with gutonc. Think of it this way. If you have a cancer patient with signs of cord compression, you're not likely sending that home. Also, if you MRI the T spine and find a met with a cord compression, you're giving steroids, admitting, and you are (or someone else is) calling rad Onc for radiation treatments. Can you 100% rule out cervical or lumbar mets with getting an MRI of those levels? No. But if you see a thoracic met with compression and there are no upper extremity symptoms the chance of a second level of cord compression in the C spine is very low. They may have a non-cord compressing met up there, but that doesn't change anything acutely in the ED. That can be up to heme Onc later to iron out. Same with a non-compressive lumbar met in that scenario.

Without upper extremity signs, you're going to find your problem in the t spine the majority of the time. That being said, if you suspect compression in a cancer patient with hard Neuro signs and you MRI the T spine and it's normal, the search goes on (I think that was likely their point) and somebody, is going to have to find the met causing the Neuro signs, whether it's in the C spine, L spine or brain. I haven't listened to the podcast you're talking about, but I doubt they were referring to shotgunning MRIs of the entire spine in the ED.
 
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Arcan57

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Did you really just try to put me into the "Specialist who doesn't get what it's like in the ED" box? Nice try. Lol.

I didn't tell him to MRI everyone with back pain. Read what I wrote. I didn't tell him he did anything wrong either. In fact, I alluded to the fact of how hard is it to pick up a spinal cord compression until it's too late. Most acute spinal cord compressions are picked up only after there's irreversible cord damage. That's the norm, unfortunately, for the reasons you state.

This is a very broad subject and a good one for a thread. My response to him was Emergency Medicine specific and will continue to be. "Imaging" or working up back pain with a red flag (extremes of age, CA history or signs like weight loss, fever, aaa risk factor, Neuro signs) could mean lots of things. Of course if you have myelopathic signs, get your MRI. By that time it's an easy sell, but also too late.

For bone mets a lot of times that can be picked up on a thoracic plain film series in the ED. I've picked that up before, as you likely have. That's a cord compression prevented and saved and someone else can get the MRI later. Also, vertebral compression fractures can be screened for on plain films in that age group and you might see a bone met causing a pathologal fracture. Also, a stone protocol ct (which I mentioned) is immensely easier to get in the ED and though not 100% sensitive for things like AAA, abscesses, or bone mets, a lot of times it may still pick those things up, or at least give a clue that further imaging is needed. I've picked up missed retro peritoneal mets on CT, also, that presented as blown off back pain, all in the ED.

The same goes for unexplained back pain in kids. It's unusual and in and of it's self often a red flag. Does that mean you MRI every kid with back pain in the ED? No. In fact, you're more likely to need to check for a uti or pyelo. I've picked up stones in kids < 10. It's not every day but it happens. Also, torsion with back/flank pain.

I know you know all this, but my point is, that I did not say or imply "MRI every back pain in the ED." You're twisting the point of my post around. I do think you should have a low threshold for some appropriate additional work up in the ED when there's red flags, and do not let the Utopian save-the-healthcare-system mantras for cost reduction get too much into your head, because no one, NO ONE that's published any of those cost containing guidelines or textbooks will stand by any of us when there's been a bad outcome, whether you followed their guidelines or not. It's my opinion that they're more likely to take cash to testify against you; see Rosen and Gabaeff.

http://www.epmonthly.com/features/current-features/gross-negligence-a-slippery-slope-for-dubious-expert-testimony/

(A good summary for students, regarding back pain "red flags," though I think their age >70 should be lower, and often is listed as low as 50: http://www.acepnow.com/article/high-value-diagnostic-approach-low-back-pain/)
What I mostly disagree with is your cut-off of age >50 for being the threshold for imaging for patients with exams consistent with mechanical back pain. It doesn't jive with my experience for detecting badness in back pain patients. It may be that I'm pulling out the AAA and high risk of malignancy patients out of the back pain bucket based on how they present, but I just don't see scans coming back positive often enough to justify ordering them in the 50-60yr group. And I worry about ct as screen due to radiation as well as an n=2 in the past year of patients with nl exams and neg abd/pel CTs that bounced back with cauda equine within a week of their initial visit.
 

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It may be that I'm pulling out the AAA and high risk of malignancy patients out of the back pain bucket based on how they present.
Maybe

n=2...neg abd/pel CTs that bounced back with cauda equine within a week of their initial visit.
2 patients that had cauda equina that had ct abd/pelvis then bounced back.

Okay...Lets think that one through. They came in 1 wk ago. They had back pain. They did not have signs of cauda equina 1 wk ago. (I'm assuming that, because if they did, the doc obviously would have ordered the MRI, then. If not, it's just a miss. Obviously, ct abd/pelvis is TFs wrong choice for cauda equina. Again, where did I say "CT everyone with back pain" or "order ct to rule out cauda equina"?) So if an MRI had been ordered day 1, when there were no signs of cauda equina, it would have shown a big disc bulge, nothing emergent, no impingement on the cauda equina and nothing changes. They're sent home to follow up in a bulging disc, and told to come back if Neuro signs/bowel/bladder-dysfunction. Then they come back 1 week later with urinary retention/bowel incontinence and it's an easy slam dunk for the MRI and admit to NS.

So whether or not the intial doc ordered a ct on the patient initially due to their age group, that changes nothing about the fact the an MRI on the first visit would not have changed management. I guess I don't get your point. The older people get, the greater their likelihood of back pain badness. If you want age 50 to get you thinking more about it, fine. If you want to use age, 60, or 70, then fine. Obviously the higher a cutoff you use, the more bad things you miss but have less unnecessary negative tests. The lower a cutoff you use, you'll have less unnecessary negative tests, but be more likely to pick things up.

It's like anything else in EM. Dial up your index of suspicion and you'll pick more things up, but have more people that rule out. Work things up less, and only when they have a "real good story" and you can be that guy that the radiologists and hospitalists love because you never order a negative imaging study and never admit anyone that doesn't rule in. You'll also miss more. Everybody needs to pick where they want to fall on the spectrum.
 
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Groove

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There's a great article on back pain from CDEM March 2014 issue written by a couple of EM Yale faculty (Della-Giustina MD, Goldflam MD). Summary:

Red Flags:

(History)
  • Age < 18 (Congenital defect, turmor, infection, spondylolysis, etc..)
  • Age > 50 (tumor, infection)
  • Trauma
  • Hx of Cancer
  • Fever, Night sweats
  • Weight loss
  • Injection drug use
  • Immunocompromised status
  • Recent genitourinary or GI procedure
  • Night pain
  • Unremitting pain
  • Pain radiating below knee
  • Saddle anesthesia
  • Fecal or urinary intontinence
  • Severe or rapidly progressive neurological deficit
(PE)
  • Fever
  • Unexpected anal sphincter laxity
  • Perianal/perineal sensory loss
  • Major motor weakness
  • Point tenderness to percussion
  • Positive straight leg raise test

High Points:

  1. Perform extremely thorough neuro exams.
  2. 85-90% of adult pts with acute back pain will have no clear diagnosis for their symptoms
  3. Most puts with back pain will have sig improvement in sx over 4-6 weeks with conservative therapy
  4. Fever is insensitive (27% tuberculosis osteomyelitis, 50% pyogenic osteomyelitis, 83% spinal-epidural abscess)
  5. Vertebral Percussion tenderness can be sensitive for bacterial infection up to 86%
  6. Pos straight leg raise is 80% sensitive for L4L5 or L5-S1 disc herniation
  7. Pos crossed straight leg raise test is highly specific for nerve root compression by herniated disc but sucks at sensitivity
  8. ESR/CRP can be useful but beware false negative --> immunocompromised pts
  9. XR if fx is suspected, AP and lateral are the only ones necessary. Oblique are rarely indicated and only drive up radiation exposure and cost.
  10. The old idea of XR first to help r/o tumors and infection and if normal move on to other imaging is antiquated as sens/spec abysmal with plain radiography. MRI for definitive diagnosis.
  11. MRI is preferred imaging modality for most patients with low back pain. Best resolution of lesions in the vertebral bodies, soft tissue, canal, cord, and best imaging of disc disease.
  12. Emergent MRI is modality of choice or suspected spinal infection (osteo, abscess) and compression.
  13. MRI indicated for routine or urgent use in eval of neoplastic processes of spine and disc disease if sx fail to resolve > 6 weeks.
  14. CT > MRI in evaluating bony detail (i.e. fractures) but will miss spinal canal lesions/infection. If they can't do MRI, get CT with myelography.
  15. In the ED, no indication to obtain an MRI for suspected herniated disc. Conservative therapy. Only get MRI if you have concern for more serious etiologies (massive herniation, epidural hematoma, infection, etc..)
  16. The classic triad of back pain, fever, neuro sx only occurs in 37% puts with abscess
  17. Do not LP if abscess is suspected.
  18. Treatment: No one NSAID better than others and use muscle relaxers only when there is assoc spasm. Studies on the benefit of steroids have been inconclusive and their use is not strongly recommended nor discouraged
Take home points:

1) Essentially: The authors seem to encourage no imaging and conservative therapy for most back pain with no red flags of less than 6 weeks duration.
2) Search for red flags in history, PE and use those to direct your diagnostic investigation
3) IV drug abusers with back pain have a spinal infection unless proven otherwise
4) MRI > CT/XR for infection/neoplasm
5) Augment diagnostic imaging with labs (ESR/CRP) for pt's with red flags for infection
6) ESR may not be elevated in immunocompromised pts

It was a fairly thorough article with many references to recent literature. I have one minor quibble and that was a part where they mentioned obtaining plain radiographs for pt's with herniated disc where diagnosis might be in doubt. They first said "treat conservatively and do not perform any diagnostic tests for the first 4-6 weeks of treatment" but then said to consider XR if there is a demonstrable neuro deficit at initial evaluation to help rule out other causes such as tumor, fx, spondylolisthesis, infection.. Essentially, all the things that they earlier stated NOT to use XR to help rule out.

Regardless, I thought it was a good article.
 
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Arcan57

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2 patients that had cauda equina that had ct abd/pelvis then bounced back.

Okay...Lets think that one through. They came in 1 wk ago. They had back pain. They did not have signs of cauda equina 1 wk ago. (I'm assuming that, because if they did, the doc obviously would have ordered the MRI, then. If not, it's just a miss. Obviously, ct abd/pelvis is TFs wrong choice for cauda equina. Again, where did I say "CT everyone with back pain" or "order ct to rule out cauda equina"?) So if an MRI had been ordered day 1, when there were no signs of cauda equina, it would have shown a big disc bulge, nothing emergent, no impingement on the cauda equina and nothing changes. They're sent home to follow up in a bulging disc, and told to come back if Neuro signs/bowel/bladder-dysfunction. Then they come back 1 week later with urinary retention/bowel incontinence and it's an easy slam dunk for the MRI and admit to NS.

So whether or not the intial doc ordered a ct on the patient initially due to their age group, that changes nothing about the fact the an MRI on the first visit would not have changed management. I guess I don't get your point. The older people get, the greater their likelihood of back pain badness. If you want age 50 to get you thinking more about it, fine. If you want to use age, 60, or 70, then fine. Obviously the higher a cutoff you use, the more bad things you miss but have less unnecessary negative tests. The lower a cutoff you use, you'll have less unnecessary negative tests, but be more likely to pick things up.

It's like anything else in EM. Dial up your index of suspicion and you'll pick more things up, but have more people that rule out. Work things up less, and only when they have a "real good story" and you can be that guy that the radiologists and hospitalists love because you never order a negative imaging study and never admit anyone that doesn't rule in. You'll also miss more. Everybody needs to pick where they want to fall on the spectrum.
What exactly does have a lower threshold for imaging in over 50 mean to you? If you're not advocating imaging everyone in that group can you elaborate what trips on your hx/physical that makes you pull the trigger? It's one thing to address it in your MDM but who do you radiate?

I brought up the CT point not because I believe there should have been an MRI initially but because in at least one of the cases the patients perception of the workup they received led to them delaying medical care. While I understand that practice styles vary, I find it useful on the nonspecific could be bad but no red flags yet patient to not do a lot of radiographic screening tests because it tends to muddy the message I'm communicating to the patient regarding return instructions.

Also, at some point it's not possible to positively change the course of the disease by increasing testing. We are running into that with cancer screening and probably are near or at that point with ACS and PE.
 

Birdstrike

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What exactly does have a lower threshold for imaging in over 50 mean to you? If you're not advocating imaging everyone in that group can you elaborate what trips on your hx/physical that makes you pull the trigger? It's one thing to address it in your MDM but who do you radiate?
I wish anything in Medicine was ever that black or white. I'm not going to lecture you or anyone else on how to practice Medicine or claim I have some fool proof, one-size-fits-all decision rule you haven't seen before. I'm not saying he messed up or than everyone over a certain age needs x, y, or z, because I said so on SDN. I was just responding to the OP. My first impression was that with the advantage of 20/20 hindsight through a retrospectoscope and since he asked, was that what stood out was the patient's age. That's all. It doesn't mean I think he messed up or that every patient over age 50 with back pain has a cord compression and needs an MRI.

In general, I'm just trying to give a little different perspective, from a little bit different vantage point than what people are used to being fed in life and on these threads. I think that I have plenty to offer the med students and residents with my posts. But honestly, I don't think that much of what I post is going to be of much interest or value to the seasoned attendings out there. I don't intend to reinvent the wheel, but only to cut through the bullsh¡t every once in a while.
 
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KiloAxe

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I wouldn't have imaged, (and definitely not gotten an xray which is rarely helpful outside of traumatic injury). There are specific criteria IMO on who needs emergent MRI for back pain, and its very uncommon in my practice. There was no sign of cauda equina syndrome on your visit, and zero neuro symptoms. imaging would have been overkill. in retrospect, we know there was a disk herniation, but that doesn't mean that the spine surgeons would have taken her immediately to the OR with NO emergent indication.

Most patients are reasonable; I discuss when we consider imaging and why it wont be helpful at this time. you go through return precautions and f/u. you'll miss plenty of things in your career, but I wouldn't consider this a miss. I would consider your workup consistent with standard of care.

Don't practice medicine to have zero miss rate. You'll be unhappy, and you'll be treating yourself and not the patient.