Advanced Practice Provider Academy

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1 (+)Dean T. Harrison, MPAS,PA C,DFAAPA Director of Mid Level Practitioners; Assistant Medical Director Clinical Evaluation Unit, Division of Emergency Medicine, Department of Surgery, Duke University Medical Center Advanced Practice Provider Academy April San Diego, CA Assessing the Patient with Low Back Pain: Tricks of the Trade Low back pain is a common complaint in patients presenting to the ED. Recognizing the patients with a serious cause for their low back pain can be difficult. The speaker will show you how to rapidly assess the low back pain patient without making mistakes. Objectives: List the red flags in the history and physical examination that may indicate the potential for a serious problem. Discuss how a goal directed physical examination can assist you in efficiently evaluating the patient with low back pain. Recognize the serious conditions presenting with low back pain that you can t afford to miss. Describe the key elements of charting in the low back pain patient. Date: 4/16/2014 Time: 8:30 AM 9:00 AM Course Number: WE 33 (+) No significant financial relationships to disclose

2 Dean T, Harrison, M.P.A.S, P.A. C., D.F.A.A.P.A San Diego, April 16 th, 2014

3 I will gladly see the next 5 patients if you would like to see this patient

4 Low Back Pain In the ED Agenda By the end of this presentation you will be able to determine the key factors and red flags in evaluating the patient with low back pain

5 Low Back Pain % of population will have lower back pain at some time in their lives Up to 85% of patients with low back pain will have no definite etiology determined for their symptoms Almost 90% of patients will have resolution of their symptoms within 1 month

6 Low Back Pain However Most Common cause of disability for person < 45 years of age 1% of the United States is disabled due to Back Pain Cost to Society Estimated to be Billon dollars/year

7 Where do we Begin? With a Quick Anatomy Review

8

9

10 How Do You Approach the Patient with Low Back Pain? Points to remember Clinical presentation will be varied from the individual requesting a work note to the patient with severe unrelenting pain.

11 Cause of Back Pain by Region Spinal Causes central disk herniation tumor infection vertebral osteomylitis,epidural abscess, TB epidural hematoma transverse myelitis ankylosing spondylitis spinal stenosis

12 Abdominal Causes of Back Pain Biliary disease cholecystitis, pancreatitis GI posterior penetrating ulcer,esophageal disease GYN Disease ovarian torsion,mass, abscess

13 Retroperitoneal Causes of Back Pain Vascular AAA, Dissection Renal stone,tumor, abscess, obstruction Pancreatic abscess, pancreatitis, mass

14 Pulmonary Causes of Back Pain Any process inflaming the posterior parietal pleura, tumor, infarction, infection, pleurisy

15 Systemic Causes of Back Pain Endocarditis and bacteremia Transfusion reactions

16 Causes of Low Back Pain Lumbar strain or sprain 70% Degenerative changes 10% Herniated disk 4% Osteoporosis compression fx 4% Spinal stenosis 3% Spondylolisthesis 2%

17 Causes of Low Back Pain Traumatic Fractures < 1% Congenital Disease < 1% Cancer 0.7% Inflammatory Arthritis 0.3% Infection 0.01%

18 History and Physical Examination Back pain can be differentiated into three categories 1 Acute pain less than 6 weeks 2 Subacute pain is between 6 and 12 weeks 3 Chronic pain has been greater than 12 weeks

19 History and Physical Examination Important questions to ask about the pain Remember Old Cars O onset L location D duration C character A alleviating factors R radiation S severity

20 Important History H/O trauma H/O constitutional symptoms H/O immunocompromised state H/O cancer Question regarding neurological deficits 1 weakness 2 paresthsias 3 anesthesia 4 gait disturbances 5 bowel or bladder incontinence 6 bilateral rapidly progressive symptoms

21 RED FLAG Patients that have had back Pain for greater than 6 weeks require further diagnostic evaluation Patients older than 50 or younger than 18 should raise concern regarding tumor or infection Patients with cancer Patients with unexplained weight loss Patients with prolonged steroid use IVDA patients Fever with back pain

22 Physical Examination Directed toward indentifying any neurological deficits All patients with back pain require and abdominal examination in addition to your muscular skeletal examination Examination of the back look for evidence of infection or trauma Neurological examination is the most important aspect of your physical examination!!

23 Straight Leg Test

24 Cross

25 Nonspecific Back Pain Majority of patients will fall into this category Also called Mechanical back pain Lumbago Back strain Pulled Back It is an episode of acute low back pain WITHOUT associated sciatica or neurologic deficits

26 Nonspecific Back Pain Usually is due to repeated stress on the lumbar spine over many years or an acute injury can initiate pain

27 Serious Conditions that You Do Not Want to Miss! Acute Disc Herniation

28 Acute Disc Herniation Only effects 1% of patients with low back pain 98% of herniated discs involve either L4 L5 or L5 S1 Most commonly occur in the forth or fifth decade of life Usually patient will complain of low back pain preceding the onset of radicular symptoms This usually signifies nerve root compression

29 Examination Findings You should be able to localize the pain to an isolated nerve root and be able to demonstrate neurological dysfunction in the distribution of that nerve root You should have a positive straight leg test along with a positive crossed straight leg test Imaging Needed MRI

30 Herniated Disc

31 Spinal Infections Vertebral osteomyelitis and spinal epidural abscess are rare However there is a high morbidity and mortality if this is missed! Occur more commonly in IVDA, immunocompromised, diabetic, and the elderly

32 Presentation Present with moderate to severe back pain May have chills, fever, night sweats Unrelenting back pain May have concomitant sciatica and neurological symptoms May present septic Elevated WBC Elevated ESR CRP

33 Workup MRI greatest accuracy CT guided Needle Aspiration LP risk of spreading bacteria

34

35 Epidural Abscess

36 Epidural Compression Syndrome Collective term encompassing spinal cord compression cauda equina syndrome and conus medullaris syndrome Due to compression of the cauda equina or spinal cord by tumor,large central disc herniation, infection or hematoma

37 Presentation Minimal to moderate back pain Sciatica in association with bilateral neurological deficits and incontinence Exam evidence of bilateral nerve root involvement Most common sensory deficient occurs over the buttock, perineum and posterior superior thighs in the saddle distribution Urinary rention

38 Treatment Stat neurosurgery consult High dose steroids Emergent MRI

39 Cauda Equina

40 Take Home Points Pitfalls Failure to consider rupturing AAA Over utilizing diagnostic test in patients with low back pain Under utilizing diagnostic testing in pediatrics who have a much higher incidence in serious disease process Failure to recognize spinal infections in high risk patients Overutilization of MRI in patients with limited h/o back pain

41 Charting Pitfalls Remember if it is not charted it was not done Charting complete history Documentation of complete neurological examination Documentation of complete back examination Documentation of clinical response to treatment Documentation of consultants time line

42 Thank You for Your Time and Attention!

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