Mizuho talks with Dr. David Della-Giustina about red flags when looking at back pain patients in the ER. Are you over 50, have had night pain for more than 6 weeks, got a fever, and you've peed your pants? Stop listening to this podcast and get an MRI.
Andrew P. - November 1, 2013 2:45 PM
Quick question regarding bilateral symptoms as a red flag... Occasionally, I will see a patient with what seems like sciatica, but it is bilateral. Does this qualify as a red flag if there are no other neurologic findings/symptoms, and no other red flags in the hpi/exam in an otherwise healthy patient?
Jennifer M. - November 12, 2013 6:22 PM
Hi, Great podcast.
I had a patient last year that I thought about when listening to this. As we know, in elderly pt, back pain can be your only complaint for aortic dissection. If an elderly female comes to the ed with unilateral leg weakness and back pain, the differential includes aortic dissection going down into the illiacs causing leg weakness, but the weakness can also be a result of epidural compression syndrome. Of course, many other dx are in the differential Those are the two big emergencies, that I would not want to miss. How do I pick ct aorta with runoff versus mri?
Todd H. - November 12, 2013 9:44 PM
I would be interested in Dr Della-Giustina's comments on the use of steroids in acute back pain. I have used this with good results for some of my back pain patients (oral medrol dosepak), particulairly those with acute radicular symptoms.
Also, do you feel there is any role for muscle relaxants for pain that seems to be muscular in origin and resulting in spasm of the muscles?
Laurence S., M.D. - November 23, 2013 4:37 AM
Stop those ridiculous sound effects-you guys are like kids with a new toy(which clearly you must have gotten recently, i.e. some freaking sound machine or something!!).
Very annoying esp. in this segment, OMG!!!
Mizuho M. - December 6, 2013 4:28 PM
Andrew & Todd, I've asked Dr.Della-Guistina to respond, so hopefully he gets back to us soon! Thanks for your comments.
Jennifer- I've come across this same dilemma, and my experience with this has been that CT is generally a much faster study, even for those of us who have access to 24/7 MRI. So while MRI might be better for looking at the spinal cord, getting a CT to rule out the dissection first (if that is higher on your ddx) might be the way to go. Then if necessary proceeding with MRI once you know you don't have a dissection. The last thing I want is my patient coding on the MR scanner, or having a delay in getting surgery to see her b/c the MRI took too long. So I think much of this is study-turn around time dependent. Hope that helps!
Thanks for listening!
David D. - December 19, 2013 7:25 AM
Thanks for the positive comments on my discussion. Here are my answers to the questions:
ANDREW: Bilateral symptoms is not a "red flag" but it is something that would make me worried, especially if the symptoms radiate below the knee. The big question is "Is the back pain radiating to both buttocks and / or thighs but not below the knees?" If so, I would be think that it is more consistent with a "nonspecific back pain" in the absence of any other symptoms. If there are associated neurological deficits, then I would definitely be worried about something compressing on the spinal cord or cauda equina. If it is pain only, then it could be spinal stenosis in an elderly patient -- that can be a back pain with bilateral symptoms. It typically worsens with walking and activity and improves with rest and forward flexion. Is this helpful??
JENNIFER: That is a tough question. If you look at the symptoms you mention, back pain with unilateral leg weakness is not a typical presentation for an aortic dissection. I am not saying that it is not possible, because it sounds like you've seen it, but I would hope that there would be something else that would steer you in the direction of aortic dissection such as sudden onset of pain, chest + back + abd pain. If not, however, and you have the concern for aortic dissection, I would get the CT with runoff to evaluate the aorta since that will kill the person and is the most emergent issue. In a patient with back pain and unilateral leg weakness, there is no reason to get an emergent MRI unless you are worried about something causing an epidural compression such as a tumor or massive midline disc (that would cause bilateral symptoms). Also, the CT will give you a "cheap" look at the spine / vertebral bodies but it does not get the evaluation inside the spinal canal. Bottom line: Get the CT scan to r/o dissection and defer the MRI work-up as an out-pt unless there are other red flags in the history / exam to raise suspicion for epidural compression.
Does that help??
TODD: Steroids are proven not to make a difference for routine low back pain. They are shown to help with a small reduction in pain for herniated discs, especially when given as epidural steroids. However, they have not been shown to cause harm when used orally for herniated disc and they are routinely given out by spine surgeons for radiculopathy. I occasionally use steroids for radicular symptoms in patients with potential herniated discs. In terms of "muscle relaxants", they are proven to be as effective as NSAIDs in the treatment of pain. Personally, I am not a fan of them as I believe they work more centrally than actually on the muscle. Additionally, there have been studies where "back experts" believed that the patient had a specific muscle spasm and the 2 "experts" disagreed on where the spasm was. Stronger evidence is that these experts pointed to the area of "spasm" and then when the checked at the time with an EMG, the patients did not have any any electronic evidence of actual spasm. Bottom line is that muscle relaxants are proven to be as effective as NSAIDs but I do not use them because most patients do not have actual spasm of the musculature and they complain of pain -- which I treat with opiates if it is more severe. However, if you're gonna use them, there is no one "best" muscle relaxant, meaning the inexpensive ones are as good as the benzos.
Does this help??
Dave
Kyle R. - March 6, 2014 11:04 AM
Hi Mizuho and gang,
Just wanted to say thanks for the great review of pathology and diagnostic approach to patients with low back pain.
As a student eagerly awaiting match day, the structure of this lecture was perfect in regards especially to the intra-lecture review of the red flags list. I know this may be redundant/boring for seasoned vets and even some residents but we students appreciate it, especially on such a "bread and butter" topic. Keep up the great work