ER patient with L1-2 transverse process fracture

[Doctodd]

id appreciate some curbside opinions......i saw a guy in the ER yesterday who fell off a chair onto his back. Internal med/ER doc put him on decadron. I cancelled it cuz he had no neuro deficits, just LBP. My biggest concern is not to make this a big issue with the doc who started the decadron. CT showed L1-2 transverse process fractures only...i ordered an MRI +/- contrast to see if it is fresh. Would you guys do anything in particular? He should be on the floor by now.....i might brace him, but i wanna see how he does.

T

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[Tenesma]

well the issue with L1/L2 fractures - usually the mechanism of the injury - would imply potential internal injuries - however if this REALLY happened off a fall from a chair then i would be shocked by internal injuries --- however, an L1/L2 transverse process fracture from a chair is kinda ridiculous - are his bones made of cheese? or is there an underlying pathology?

recommend analgesics, anti-inflammatories and muscle relaxants - let him know that it will take a month or two for it to heal.... don't know what a brace will add to the issue other than make him stiffer

would avoid injections

decadron not a good idea - agreed

 

[Spine Specialist]

id appreciate some curbside opinions......i saw a guy in the ER yesterday who fell off a chair onto his back. Internal med/ER doc put him on decadron. I cancelled it cuz he had no neuro deficits, just LBP. My biggest concern is not to make this a big issue with the doc who started the decadron. CT showed L1-2 transverse process fractures only...i ordered an MRI +/- contrast to see if it is fresh. Would you guys do anything in particular? He should be on the floor by now.....i might brace him, but i wanna see how he does.

T

If no neurological deficit or other injuries ruled out: Rest, Cryotherapy to reduce muscle spasm and NSAID will work. Bracing is not a bad idea. Why decadron? On exam, did he have pain on flexion of Hips ( due to iliopsoas insertion?? Just wondering...

 

[Doctodd]

the ER docs just shotgun decision the decadron i think just to be safe if there is any deeper injury. To be fair to them, they dont specialize in this and they are slammed. They just triage and send to IM, who then sends to me. Regarding his bones.....he is an older man. I dont even know if they are acute....that is why i ordered the MRI to see if any edema.

and yes i had him lie on a bag of ice...i couldnt really flex his hips cuz of the guarding.....will try more today.

thx

 

[spondy14]

I think bracing would be very helpful, for both pain and spasm control. Of course analgesics prn, muscle relaxers at night, and the MRI will tell the rest of the story. Decadron in this case is quite strange, especially if they saw the fractures? Bone scan will also help if there is still a question of acute vs. chronic.

 

[ampaphb]

Dexa and bisphosphonates or Forteo, depending on how low his T score is

decadron will make the osteoporosis worse, so should be avoided

 

[SSdoc33]

uhhhh.... whats the difference between "anti-inflammatories" and decadron. same idea, right? i assume that the CT scan was done later, and that the ER doc gave the steroids without knowing about the fracture. i know i give out prednisone for acute LBP all the time. doesnt sound too off the wall to me. back pain with resisted hip flexion is what you'd expect to find 2/2 the psoas attachment.

 

[Tenesma]

just curious what your literature is for steroids in acute back pain - can't find any decent articles - please advise

 

[SSdoc33]

Malanga GA, et al. Pharmacologic Treatment of Low Back Pain. In Physical Medicine and Rehabilitation State of the Art Reviews, Philadelphia, Hanley and Belfus Vol.13, No.3, October, 1999

not the hardest of evidence, but there's enough there to justify its use. i think we'd agree that EBM in pain medicine isnt the greatest.

i generally use it for acute radiculopathy or a suspected annular tear. probably not for a fall off a chair, but its not off the wall.

 

[Mister Mxyzptlk]

probably not for a fall off a chair, but its not off the wall.

What about if you fall off the wall, or fall off a chair that was on the wall?

 

[joshmir]

specifically for acute LBP/monoradicular pain.....


you guys think there is a difference in terms of which steroid to choose?

would you order an IV dose in ER followed by a PO taper?

the solumedrol pred-pak makes the taper easy for the pt



also, if the pt failed conservative tx, would having gotten an initial course of IV/PO steroidsit change your timing for a LESI?

 

[Doctodd]

i personally dont use steroids for plain old acute low back pain, and if it is radicular i dont use IV or PO secondary to side effects.....i would do a LTFESI