FRCEM FINAL SBA eBook 1(Preview)

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26 <strong>FRCEM</strong> Final Metastatic Tumor to the Spine: Compression and Instability c. Spinal epidural abscess • Spinal epidural abscess is a rare but serious cause of back pain. • Initial symptoms (eg, fever and malaise) are often nonspecific; over time, localized back pain may be followed by radicular pain and, left untreated, neurologic deficits. • Risk factors include recent spinal injection or epidural catheter placement, injection drug use, and other infections (eg, contiguous bony or soft tissue infection or bacteremia). • Immunocompromised patients may also be at higher risk. Treatment of spinal epidural abscess is reviewed in detail elsewhere. d. Vertebral Osteomyelitis • The majority of patients with vertebral osteomyelitis will present with back pain, which gradually increases over weeks to months; fever may or may not be present. Vertebral Osteomyelitis • The intervertebral disc may also be become infected (discitis), and the clinical presentation (positional discomfort, pain to palpation, neurologic signs/symptoms) may vary depending upon the extent of the infection. • The incidence of vertebral osteomyelitis generally increases with age, and men are more commonly affected than women. Many cases are thought to be health carerelated or postprocedural from hematogenous spread of bacteremia. Less specific risk factors include an immunocompromised state and injection drug use. 3. Less serious, specific etiologies a. Vertebral compression fracture • Approximately 4 percent of patients presenting in the primary care setting with low back pain will have a vertebral compression fracture 20 . While some produce no symptoms, other patients present with acute onset of localized back pain which may be incapacitating. • There may be no history of preceding trauma. • Risk factors for osteoporotic fracture include advanced age and chronic glucocorticoid use. A history of an osteoporotic fracture is a risk factor for subsequent fractures, which can be mitigated by pharmacologic therapy. Approximately 3 to 4 percent of patients who present in primary care settings with low back pain have a symptomatic disc herniation or spinal stenosis. Vertebral compression fracture (Radiopaedia) Spinal epidural abscess in brucellosis | BMJ Case Reports 20 Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med 2002; 137:586. Acute & Major Presentations Moussa Issa Bookstore
Section I: Major and Acute Presentations 27 b. Radiculopathy • Radiculopathy refers to symptoms or impairments related to a spinal nerve root. • Damage to a spinal nerve root may result from degenerative changes in the vertebrae, disc protrusion, and other causes. • The clinical presentations of lumbosacral radiculopathy vary according the level of nerve root or roots involved. • Over 90 percent are L5 and S1 radiculopathies 21 . • Patients present with pain, sensory loss, weakness, and/or reflex changes consistent with the nerve root involved. • Many patients with symptoms of acute lumbosacral radiculopathy improve gradually with supportive care. • Sciatica is a nonspecific term used to describe a variety of leg or back symptoms. • Usually, sciatica refers to a sharp or burning pain radiating down from the buttock along the course of the sciatic nerve (the posterior or lateral aspect of the leg, usually to the foot or ankle). Most sciatica is attributable to radiculopathy at the L5 or S1 level from a disc disorder. c. Spinal stenosis • Lumbar spinal stenosis is most often multifactorial. Spondylosis (degenerative arthritis affecting the spine) spondylolistheses, and thickening of the ligamentum flavum are the most common causes, typically affecting patients >60 years. • Ambulation-induced pain localized to the calf and distal lower extremity resolving with sitting or leaning forward ("pseudoclaudication" or "neurogenic claudication") is a hallmark of lumbar spinal stenosis. • Other symptoms of lumbar spinal stenosis can include back pain and sensory loss and weakness in the legs, though many patients may present with a normal neurologic exam. Spinal stenosis 21 Acute low back problems in adults: assessment and treatment. Agency for Health Care Policy and Research. Clin Pract Guidel Quick Ref Guide Clin 1994; :iii. • Symptoms of neurogenic claudication can usually be distinguished from vascular claudication. Rare patients develop a cauda equina syndrome. • Patients often have symptoms only when active. Most patients with spinal stenosis related to osteoarthritis will have stable symptoms over time. 4. Other Etiologies • Ankylosing spondylitis • Osteoarthritis • Scoliosis and hyperkyphosis • Psychologic distress 5. Etiologies outside the spine • Piriformis syndrome • Sacroiliac joint dysfunction • Bertolotti's syndrome CLINICAL EVALUATION HISTORY • While it may not be possible to define a precise cause of low back symptoms for most patients, it is important to evaluate for evidence of specific etiologies of back pain. • The history should include location, duration, and severity of the pain, details of any prior back pain, and how current symptoms compare with any previous back pain. • We also ask about constitutional symptoms (eg, unintentional weight loss, fever, or night sweats), history of malignancy, precipitants or precipitating events, therapies attempted, neurologic symptoms (eg, weakness, falls or gait instability, numbness or other sensory changes, or bowel/bladder symptoms), stability or progression of symptoms, history of recent bacterial infections (particularly bacteremia), recent history or current use of injection drugs, history or current use of corticosteroid medications, and recent history of epidural or spinal procedures. Patients should also be evaluated for social or psychologic distress that may be contributing. Potentially useful items are a history of failed previous treatments, substance use disorder, and disability compensation. Screening for depression may be helpful. Features that may suggest underlying systemic disease include history of cancer, age >50 years, unexplained weight loss, duration of pain >1 month, nighttime pain, and unresponsiveness to previous therapies. Documented fevers, injection drug use, recent bacterial infection (particularly bacteremia), or recent epidural or spinal instrumentation increase the suspicion of spinal infection. PHYSICAL EXAMINATION • Inspection of back and posture – can reveal anatomic abnormalities such as scoliosis or hyperkyphosis. • Palpation/percussion of the spine – usually performed to assess vertebral or soft tissue tenderness. Vertebral tenderness is a sensitive, but not specific, finding for spinal infection, and may also be seen in patients with vertebral metastases and osteoporotic compression fracture. Acute & Major Presentations Moussa Issa Bookstore
Page 1 and 2: Disclaimer i
Page 3 and 4: Disclaimer iii Disclaimer Copyright
Page 5 and 6: Acknowledgments v Acknowledgments T
Page 7 and 8: Table of Contents vii 11. Dental Em
Page 9 and 10: Table of Contents ix 34. Psychiatri
Page 11 and 12: Section I: Major and Acute Presenta
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