A disconcerting cause of

back pain
Doctor Chad
PulmCrit.com
Pulmonary & Critical Care

Objectives
Review a case of severe low back
pain in a critical care setting
Appreciate the importance of the
history and physical in assessing
low back pain
Review the emergency causes of
low back pain, including the
work-up and management

Who is this?

William Osler (18491919)

Canadian physician and Father of
Modern Medicine
One of four founding professors of
Johns Hopkins Hospital
Osler created the first internal
medicine residency program
Pioneer of bedside teaching for
medical students

Case Presentation

Chief Complaint:
Back pain
HPI
63 year old man who presents with severe
lower back pain
First noted pain when walking dog 4 days
prior to admission
Came to ED given dexamethasone,
toradol and dilaudid
Sent home with mobic, medrol dose pack
and percocet
Went to an outpatient clinic and received a
steroid hip injection

Case Presentation contd

Pain did not improve in fact it got worse
Was unable to ambulate due to pain
Pain was sharp, in left lower back/flank
radiating to groin
On admission denies any chills, vomiting
ROS: Positive for subjective fevers,
diarrhea, weight loss, nausea and poor
PO intake.

Past Medical History

HTN
Degenerative Joint Disease
Psoriatic arthritis
Anxiety and Depression
Hypercholesterolemia
Benign Prostatic Hyperplasia
Vocal Cord Disease
Sleep Apnea but does not use CPAP

Medications

ASPIRIN 81 MG EC TABLET
ATORVASTATIN 10 MG ORAL TABLET
CARISOPRODOL (SOMA)
FINASTERIDE 5 MG ORAL TABLET
MELOXICAM 15 MG ORAL TABLET
METOPROLOL 50 MG EXTENDED-RELEASE
TABLET
OXYCODONE
TERAZOSIN 10 MG CAPSULE
VALSARTAN 160 MG ORAL TABLET

Social History & Family Hx

Social History
He works as an accountant
Lives with his roommate
The patient denies any tobacco use
never smoker, no alcohol use.
Denies any recreational and IV drug use
Family History
Mother Dementia
Father - Emphysema

PE

Vitals: 97.6 F (36.4 C), BP: 97/55 mmHg, Heart Rate: 89 Resp Rate: 16,
SpO2: 97 %/RA
General: Alert, cooperative, mild distress, appears stated age, hoarse
voice.
Head: Normocephalic, without obvious abnormality, atraumatic.
Eyes: Conjunctivae/corneas clear. PERRL, EOMs intact.
Throat: Lips, mucosa, and tongue normal. Teeth and gums normal.
Neck: Supple, symmetrical, trachea midline, no adenopathy, thyroid: no
enlargment/tenderness/nodules, no carotid bruit and no JVD.
Pulmonary: Clear to auscultation bilaterally.
Chest wall: No tenderness or deformity.
Heart: Regular rate and rhythm, S1, S2 normal, no murmur, click, rub or
gallop.
Abdomen: Soft, non-tender. Bowel sounds normal. No masses, No
organomegaly.
Extremities: Extremities normal, atraumatic, no cyanosis or edema. SLR
negative
Pulses: 2+ and symmetric all extremities.
Back: patient defers exam for now, states his pain is too severe to

What is the differential diagnosis for

his low back pain?

Anatomy of the Lumbar

Spine

EB Medicine 2013

EB Medicine 2013

Labs on admission

Troponin 1.42
CBC 2.5>14.4/42<82
Na 131 /K 4.4 Cl 96/ HCO3 20 BUN 35/ Cr 0.8 Gluc 164
Anion Gap 15
Lactate 2.9
Calcium, Serum 7.8
Albumin 2.2
Alkaline Phosphatase 48
ALT 21
AST 40
Bilirubin, Direct 1.7 Indirect 0.4 Total 2.1
Total Protein 4.4

Lumbar X-ray obtained

in ED 2 days before
admission

Significant joint space narrowing at

L4-L5. End plate degenerative change
at L4-L5 and L5-S1. Disk space
narrowing at L5-S1. Facet athropathy
at L4-L5 and L5-S1. No acute fracture.

MRI Lumbar spine (no gadolinium) in

ED 2 days before admission

Hospital Course
Admitted to the medical floors
Started on pain control with
oxycodone, dilaudid and muscle
relaxants robaxin
Reviewed MRI lumbar spine
PT evaluation
Home medications continued

Day 2
Became hypotensive, febrile, abdomen became
distended, developed bloody diarrhea, nausea,
vomiting and epigastric pain.
Lactate elevated (3.6), surgery consult was called for
evaluation for SBO
Hypotension was refractory to multiple fluid boluses
(7Liters)
NGT output suspicious for coffee ground emesis
He was transferred to the ICU shortly thereafter for
continuing care.
KUB performed this morning demonstrated dilated
loops of bowel concerning for ileus vs SBO, no free air.

Labs on ICU transfer

Troponin I 1.42
CBC 1.9>12.4/42<82
Na 132 /K 4.3 Cl 100/ HCO3 16 BUN 65/ Cr 1.8 Glucose 125
Anion Gap 16
Calcium, Serum 7.0
Lactate 3.7
Albumin 1.9 AP 51 ALT 46 AST 100
Bilirubin, Direct 2.6 Indirect 0.4Total 3.0
Total Protein 4.1 (L)
ABG 7.33 28 93 14.8 96.5% on 5L nc
Blood cultures x 2 Staph Aureus
UA Positive Staph Aureus >100,000 CFU in Urine

CXR on Transfer

Day 2 Continued
Central line placed and Vasopressors started
Surgery consult for concern for SBO
recommend NGT to suction (decompress)
Broad spectrum antibiotics (vancomycin and
zosyn IV) initiated
GI consulted for UGIB PPI started
TTE negative for Vegetation
Low back pain continued Pain
management consulted

Problem List Day 3 ICU

Septic Shock requiring vasopressors
Nodules, consolidations and pleural effusions on CT
Chest
SBO vs ileus
Thrombocytopenia
Leukopenia
AKI
NSTEMI
Transaminitis
Excruciating back pain
Afib with RVR

WHAT IS THE DIFFERENTIAL

DIAGNOSIS FOR BACK PAIN AT THIS
TIME?

WHAT WORK UP WOULD

YOU OBTAIN AT THIS POINT?

Day 4
Cultures remained positive for MSSA
UA suggestive of MSSA
WBC scan performed:
1. Findings consistent with osteomyelitis at T4-T5 and
L3-L4 as described above.
2. Findings suspicious for inflammatory/infectious
process of the left hip.
3. Infectious process of the right mid and left lower
lung.
4. Likely inflammatory/infectious process of the colon.

Cr. Improved so MRI with Gad obtained

T2 weight thoracic sag

T4-T5 osteomyelitis and probable disc space infection with an

epidural

T2 weight Sag Lumbar

Disc space infection L3-4 with epidural pannus extending from L1 to L5

with moderate central canal stenosis at L3 and L4. Involvement of both
psoas muscles.

Hospital Course continued

Came off pressors and was able to leave the ICU
Left hip arthrocentesis and fluid grew MSSA
EGD demonstrating duodenal ulcers and multiple
gastric ulcers
Blood cultures eventually sterilized after 1 week
Back pain improved after draining psoas abscess
SBO improved and diet advanced
Leukopenia and thrombocytopenia improved
Spine consulted conservative management

Diagnosis
T4-T5 osteomyelitis, L3-L4 diskitis and
epidural phlegmon with mild cord
compression
MSSA Bacteremia with UTI and
pulmonary dissemination
L hip MSSA Septic Arthritis

Acute Low Back Pain

Low back pain is the most common type of
pain reported by adults in the United States
26% of the population reporting pain lasting
at least a day in the past 3 months
1% of the United States workforce
considered permanently disabled by
lumbago.
In 1998, direct healthcare costs attributed
to lower back pain - estimated at $90 billion

Definitions: Acute Low Back

Acute low back pain:Pain
Symptoms lasting < 4

weeks (up for 3 months)

Chronic Back pain: Pain syndrome lasting longer
than 3 months.
Sciatica: Leg pain that localizes to lumbar sacral
nerve roots(90% of pathology occurs at L4-L5 and
L5-S1 levels.)
Spondylosis: Degenerative arthritis of the spine
Disc protrusion, extrusion, and sequestration
Protrusion, the disc is intact but out of place.
Extrusion, the gelatinous nucleus pulposus is
squeezed out from a tear in the annulus
fibrosus.
Sequestration, some parts of the disc nucleus

Definitions: Acute Low Back

Pain
Spinal stenosis: Crowding of the spinal canal, either by
osteoarthritis, osteophytes, ligamentous thickening,
and/or bulging intervertebral discs
Myelitis: An inflammatory condition that affects the spinal
cord. (often white matter and demyelination are involved)
Cauda equina syndrome: Compression of the cauda
(nerve roots)
Spondylolisthesis: Vertebra slips out of position in relation
to the vertebra beneath it.

Evaluation of the low back pain

patient
Clinicians should conduct a focused history
and physical examination to help place
patients with low back pain into 1 of 3 broad
categories:
1. Red Flag low back pain (potentially serious)
2. Back pain potentially associated with
radiculopathy or spinal stenosis
3. Nonspecific back pain (most common)
(strong recommendation, moderate-quality
evidence).
Ann Intern Med. 2007;147(7):478-491

Physical Exam in Acute

Lumbago
It is fundamental to perform a systematic
neurologic examination.
Include pertinent negatives and positives
regarding strength, sensory, reflexes, gait,
rectal sensation examination and assessment
for urinary retention
The PE findings (or lack of findings) should be
the foundation of the decision to pursue
imaging
More than 90% of disc herniations occur at the
L4/L5 or L5/S1 levels so a focus on this level

When to Obtain imaging

Most low back pain self resolves in 4 to 6 weeks so imaging
is not recommended* in patients without red flags
A meta-analysis of 6 randomized trials of 1800 patients
found no outcome differences between routine care and no
imaging and patients who underwent imaging with plain xray, CT, or MRI
Additionally, MRI reveals many abnormalities in
asymptomatic patients.
In a study of asymptomatic patients aged 60, 36% had a
herniated disc, 21% had spinal stenosis, and 90% had a
degenerated or bulging disc.

Plain Radiographs
Routine plain films are not indicated - very low for an
intervenable lesion or pathology
In a study of 68,000 radiographs, clinically unsuspected
lesions occurred in 1:2500 patients aged 20 to 50 years.
X-ray is recommended in patients who have:
Direct trauma-related back pain
Suspected of having a possible vertebral compression fracture
Young patients with lower back pain where ankylosing
spondylitis is suspected

After Conservative
Management
In patients with low back pain and
radiculopathic symptoms who are still
symptomatic after 4 weeks of
conservative management and selfcare
Imaging should be discussed that can
be intervened upon i.e. injection
therapy and surgery.
Usually MRI is preferred

WITH THE HIGH PREVALENCE OF LUMBAGO,

WHEN DOES IT BECOME AN EMERGENCY?

T2-weighted sagittal MRI of the spine

showing osteomyelitis at T12 (top arrow)
and partial cord compression at L1 (bottom
arrow).

AAFP

Acute Low Back Pain

Emergencies

Cauda Equina Syndrome

Abdominal Aortic Aneurysm Rupture
Spinal Hematoma
Epidural Abscess

In CASE of Emergency

Cauda Equina Syndrome

Cauda equina provide motor and sensory function
to the lower extremities, perineum, and bladder.
Herniated disks are most common lesions causing
cauda equina syndrome
Other causes are tumors, spinal stenosis,
infection, and hematoma
Presentation: low back pain, b/l weakness in lower
extremities, saddle anesthesia, and abnormalities
in bladder sensation and function (complete
versus incomplete syndromes)
TIP: Measure post void residual (PVR). PVR > 300
ml is always abnormal.
Diagnosis: MRI or CT myelogram is needed to
make this diagnosis.

Abdominal Aortic Aneurysm Rupture

Abdominal aortic diameter > 3 cm is aneurysmal (1/1000
patients)
Abdominal aortic aneurysms are uncommon in patients
aged < 60 years.
An aneurysms size correlates with risk of rupture
0.5% rupture risk for aneurysms < 4 cm and 3%-15% for
aneurysms 5 cm-5.9 cm.
Presentation: contained rupture can cause abdominal pain,
back pain, and groin pain, and it may be associated with
nausea, diaphoresis, or syncopal symptoms.
TIP: May assess aortic size with bedside ultrasound.
Diagnosis: CT scan with IV contrast and vascular surgery
consultation are key

Spinal Hematoma
TIP: Spinal epidural hematomas are rarely
spontaneous. Usually related to trauma,
postoperative spinal surgery,
anticoagulation, thrombolysis, lumbar
puncture, epidural anesthesia,vascular
malformation, or chiropractic
manipulation.
Presentation: Back pain and possible
neurologic complaints
Diagnosis: A low threshold for imaging
with MRI with Gad or CT myelogram with
contrast is needed in suspected patients
Reverse of coagulopathy, and patients

Epidural Abscess
Epidural abscess is a rare condition (0.2-2.8
cases/10,000/y)
Most common in the 60- to 70-year age group
Risk factors are diabetes mellitus, alcoholism,
AIDS/immunocompromised states, cancer,
and IVDU, trauma and spinal surgery
20% of patients will have no predisposing
factors
Staphylococcus aureus most common
organism

Epidural Abscess Locations

Epidural Abscess
Posterior epidural abscesses tend to be related to a
distant focus
Anterior infections are generally related to
osteomyelitis or diskitis (which can be related to a
distant focus or contiguous spread, such as psoas
abscess)
Presentation: Nonspecific - can include fever, back
pain, and malaise
Diagnosis: MRI with gad (preferred) or CT myelogram
with contrast
Treatment: 4-6 weeks antibiotics and consider
surgical decompression.

Spinal Epidural Abscess Experience with 46 Patients

Chart review 46 patients (36 men and 10 women)
with spinal epidural abscess over a 10-year period
Risk factors: diabetes (46%), frequent venous
puncture (35%), spinal trauma (24%), and history
of spinal surgery (22%)
ESR was elevated uniformly (mean, 86.6 mm/h)
Staphylococcus aureus was the most common
cause (39%)
Presentation: Localized spinal pain (89%),
paralysis (80%), fever/chills (67%), and radicular
pain (57%)
Journal of Infection (2002) 45: 7681

William Osler

The key to this case?

"Listen to your patient, for he is telling you the

References
Andersson GB. Epidemiological features of
chronic low-back pain. Lancet.
1999;354(9178):581-585. (Review)
Chou R, Qaseem A, Snow V, et al. Diagnosis and
treatment of low back pain: a joint clinical
practice guideline from the American College of
Physicians and the American Pain Society. Ann
Intern Med. 2007;147(7):478-491. (Clinical
practice guideline)
NICE. National Institute for Health and Clinical
Excellence - low back pain (CG88). 2009. (Clinical
practice guideline)
An Evidence-Based Approach To The Evaluation
And Treatment Of Low Back Pain In The

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