Rosen & Barkin's 5-Minute Emergency Medicine Consult (635 page)

• Delirium
  
• Dystonic Reaction
  
• Neuroleptic Malignant Syndrome
  
• Psychosis, Acute
  
• Psychosis, Medical vs. Psychiatric
  
• Violence, Management
  

CODES

• 295.10 Disorganized type schizophrenia, unspecified
  
• 295.20 Catatonic type schizophrenia, unspecified state
  
• 295.90 Unspecified schizophrenia, unspecified state
  

BASICS

• Pain that radiates from the back into buttocks and lower extremity distal to knee, with or without sensory or motor deficits:
  
  • 95% sensitive, 88% specific for herniated disc (HD)
    
  • 3–5% lifetime prevalence
    
  • Peaks 4th to 5th decade
    
  • 2–10% of low back pain
    
  • 95% L5 or S1 nerve root
    
  • 90% improve with conservative management
    
  • Radicular symptoms usually resolve within 6 wk
    
  • 5–10% require surgery
    

• Protrusion of colloidal gel (
  nucleus pulposus
  ) through weakened surrounding fibrous capsule (
  annulus fibrosis
  )
  
• Risk factors:
  
  • Smoking
    
  • Repetitive lifting/twisting
    
  • Vehicular/machinery vibration
    
  • Obesity
    
  • Sedentary lifestyle
    

DIAGNOSIS

• Low back pain precedes onset of leg pain
  
• Leg pain predominates with time
  
• Sharp, well localized, radiates distal to knee
  
• Exacerbated by activities that increase intradiscal pressure:
  
  • Valsalva maneuver
    
  • Cough
    
  • Nerve-root tension (sitting, straight leg raise)
    
• Relieved by decreasing pressure/tension:
  
  • Lying supine
    
  • Walking
    
• Paresthesia is the most common sensory symptom
  

• Neurologic exam (motor, sensory, deep tendon reflexes)
  
• L4 root/L3–L4 disc:
  
  • Knee extension/hip adduction
    
  • Anteromedial leg/knee/medial malleolus
    
  • Patellar reflex
    
• L5 root/L4–L5 disc:
  
  • Great toe and foot dorsiflexion
    
  • Dorsomedial foot/1st web space
    
  • No reflex
    
• S1 root/L5–S1 disc:
  
  • Foot plantarflexion
    
  • Posterior leg/lateral malleolus/dorsolateral foot
    
  • Achilles reflex
    
  • Rectal exam (tone, sensation)
    
• Straight leg raise:
  
  • Elevate ipsilateral leg by heel 30–60° with or without dorsiflexing foot
    
  • Reproduces radicular pain past knee
    
  • 80% sensitive for HD
    
• Crossed straight leg raise test (pathognomonic):
  
  • Elevate contralateral leg
    
  • Pain in involved leg
    
  • Less sensitive but very specific for HD
    

• Complete history and physical exam
  
• See below for test indications
  

• Indicated if clinical suspicion for differential diagnoses (DDX), not limited to:
  
  • CBC
    
  • ESR/CRP
    
  • UA
    

PA/Lateral of LS spine

• Helps to rule out some DDX
  
• Indications:
  
  • Extremes of age (<20, >55 yr)
    
  • Unresolved back pain (>4–6 wk) despite conservative treatment
    
  • Red flags on history and physical exam:
    
    • Trauma
      
    • Constitutional symptoms (fever, unexplained weight loss, malaise)
      
    • History of cancer
      
    • Immunocompromised
      
    • IV drug abuse
      
    • Recent bacterial infection
      
    • Worse at night/wakes patient from sleep
      
    • Fever
      
    • Midline point tenderness
      
    • Neurologic deficits
      

MRI (Criterion Standard)

• Indications:
  
  • Acute, severe neurologic deficits (order from ED)
    
  • Suspicion of infectious etiology of back pain:
    
    • Epidural abscess
      
    • Osteomyelitis
      
    • Discitis
      
  • 6 wk failed conservative therapy (order on outpatient basis)
    
  • Disc disease (>25%):
    
    • Incidental finding on MRI in asymptomatic patients
      
    • No relationship between extent of protrusion and degree of symptoms
      

CT Myelogram

• Rarely used alternative for MRI
  
• CT better at bone details
  

• Postvoid residual (PVR):
  
  • Overflow incontinence = PVR >100 mL, suspect cauda equina syndrome
    

• Lumbosacral strain
  
• Degenerative joint disease
  
• Spondylolisthesis
  
• Hip/sacroiliac joint (infection, fracture, bursitis)
  
• Pneumonia, pulmonary embolus
  
• Pyelonephritis, renal calculi
  
• Ectopic pregnancy, pelvic inflammatory disease
  
• Abdominal aortic aneurysm (AAA)
  
• Peripheral vascular disease (claudication)
  
• Herpes zoster
  
• Psychological: Functional or secondary gain (drug seeking, disability)
  
• Irritating lesion affecting a lumbosacral nerve anywhere along its route:
  
  • Brain:
    
    • Thalamic or spinothalamic tumor, hemorrhage
      
  • Spinal cord (
    myelopathy
    ):
    
    • Spinal stenosis, tumor, hematoma, infection (epidural abscess, discitis, osteomyelitis)
      
  • Root (
    radiculopathy
    ):
    
    • Intradural: Tumor, infection
      
    • Extradural: HD, lumbar spine/foraminal stenosis (pseudoclaudication), spondylolisthesis, cyst, tumor, infection
      
  • Plexus (
    plexopathy
    ):
    
    • Tumor, AAA, infection (iliopsoas abscess), hematoma (retroperitoneal)
      
  • Peripheral nerve (
    neuropathy
    ):
    
    • Toxic/metabolic/nutritional, infection, trauma, ischemia, infiltration, compression, entrapment
      

• Usually secondary to trauma or serious underlying medical disease (e.g., leukemia); consider complete workup
  
• <10 yr:
  
  • Infection
    
  • Tumor
    
  • Arteriovenous malformation
    
• ≥10 yr:
  
  • Traumatic HD
    
  • Spondylolisthesis
    
  • Scheuermann disease
    
  • Tumor
    

• Ectopic pregnancy
  
• Labor
  
• Pyelonephritis
  
• Musculoskeletal
  

TREATMENT

Full spine precautions for trauma victims

Evaluate for neurosurgical emergency

Pain relief:

• NSAIDs 1st line
  
• Muscle relaxants, opioids as needed in acute phase
  

• NSAIDs:
  
  • Ibuprofen (Motrin, Advil): 600–800 mg (peds: 5–10 mg/kg/dose) PO TID--QID
    
  • Naproxen (Naprosyn, Aleve): 500 mg PO BID
    
• Muscle relaxants (short term):
  
  • Cyclobenzaprine (Flexeril): 5--10 mg TID
    
  • Diazepam (Valium): 2–10 mg (peds: 0.1 mg/kg/dose) PO TID--QID
    
  • Methocarbamol (Robaxin): 1,000–1,500 mg PO QID
    
• Opioids (short term):
  
  • Hydromorphone (Dilaudid): 2–4 mg PO/0.5–2 mg IM/IV q4–6h PRN
    
  • Morphine sulfate: 2–10 mg (peds: 0.1 mg/kg/dose) IM/IV q2–4h PRN
    
  • Codeine 30 mg + acetaminophen 300 mg; do not exceed acetaminophen4 g/24 h
    
  • Hydrocodone 5 mg + acetaminophen 300 mg; do not exceedacetaminophen 4 g/24 h
    

FOLLOW-UP