Rosen & Barkin's 5-Minute Emergency Medicine Consult (671 page)

• Lower threshold for ordering imaging studies.
  
• Progressive slipping more likely to occur than in adults.
  

• Tuberculosis (Pott disease)
  
• Discitis
  
• Bone or spinal cord tumor
  
• Pyelonephritis
  
• Retroperitoneal infection
  
• Injury to muscles or joints of back
  
• Congenital hip dislocation
  
• Rickets
  
• Ruptured intervertebral disc
  
• Vascular claudication
  
• Osteomyelitis
  
• Osteoid osteoma
  
• Aortic aneurysm
  

TREATMENT

Spinal precautions are not needed unless there is a history of recent trauma.

Vigorous attempts at traction should not be pursued.

• Pain control and muscle relaxants as clinically needed
  
• Supportive therapy if symptoms are mild
  
• Restrict activities if repetitive trauma is likely aggravating cause (e.g., sports) for 3–6 wk, followed by reintroduction of activity when asymptomatic.
  
• Consider antilordotic braces (controversial) or physical therapy.
  
• Orthopedic consult or referral if symptoms are moderate to severe or unresponsive to supportive care
  
• Surgical intervention typically consists of spinal fusion in the flexed position:
  
  • 50% of symptomatic patients with spondylolisthesis may require surgery.
    
• All symptomatic patients with grade III or IV spondylolisthesis should probably undergo surgery.
  
• Exercises are not of proven benefit.
  

• Activity restriction is not necessary if minimal or no symptoms.
  
• Literature suggests good outcome for young athletes with conservative treatment.
  

• Muscle relaxants:
  
  • E.g.—methocarbamol: 1,000–1,500 mg PO QID (peds: Safety and effectiveness for children <12 yr of age not established)
    
  • Diazepam: 2–10 mg PO TID–QID
    
  • Cyclobenzaprine: 5–10 mg PO TID (peds: Safe for ages >15 yr old)
    
• NSAIDs:
  
  • E.g.—ibuprofen: 200–800 mg PO TID–QID (peds: 5–10 mg/kg PO q6h)
    
• Opioids (doses can vary on oral medications):
  
  • Example—morphine sulfate: 0.1 mg/kg up to 2–4 mg increments IV.
    
  • Acetaminophen/hydrocodone: 5/500 mg 1–2 tabs PO QID; do not exceed acetaminophen 4 g/24 h (peds: Do not exceed 5 doses of 10–15 mg/kg acetaminophen in 24 hr)
    
  • Acetaminophen/oxycodone: 5/325 mg 1–2 tabs PO QID; do not exceed acetaminophen 4 g/24 h (peds: Do not exceed 5 doses of 10–15 mg/kg acetaminophen in 24 hr)
    
  • Acetaminophen/codeine: 300/30 mg 1–2 tabs PO QID (peds: 0.5–1 mg/kg codeine PO q4–6h; max. 60 mg/dose codeine; 1 g/dose, 75 mg/kg/d up to 4 g/d >3 yr old); do not exceed acetaminophen 4 g/24 h (peds: Do not exceed 5 doses of 10–15 mg/kg acetaminophen in 24 hr)
    

FOLLOW-UP

• Inability to walk
  
• Inability to cope at home due to pain or social situation
  
• New or progressive neurologic deficit
  

• Orthopedic follow-up arranged
  
• Social support system in place
  
• Pain control
  
• Patient education
  

Close follow-up is mandatory.

• Clifford R, Wheeless III.
  Wheeless Textbook of Orthopaedics.
  Spondylolysis/Spondylolisthesis. Accessed on April 25, 2012.
  
• Congeni J, McCulloch J, Swanson K. Lumbar spondylolysis. A study of natural progression in athletes.
  Am J Sports Med
  . 1997;25(2):248–253.
  
• Iwamoto J, Takeda T, Wakano K. Returning athletes with severe low back pain and spondylolysis to original sporting activities with conservative treatment.
  Scand J Med Sci Sports
  . 2004;14(6):346–351.
  
• Tsirikos AI, Garrido EG. Spondylolysis and spondylolisthesis in children and adolescents.
  J Bone Joint Surg Br.
  2010;92(6):751–759. doi:10.1302/0301-620X.92B6.23014.
  

CODES

• 738.4 Acquired spondylolisthesis
  
• 756.11 Spondylolysis, lumbosacral region
  
• 756.12 Spondylolisthesis
  

BASICS

• Infection of ascites fluid without an evident intra-abdominal surgically treatable source:
  
  • Ascites fluid polymorphonuclear leukocyte count (PMN) >250/mL with a positive bacterial peritoneal fluid culture
    
• Must be distinguished from secondary bacterial peritonitis:
  
  • Nonsurgical management of secondary bacterial peritonitis carries 100% mortality.
    
  • Surgical management of spontaneous bacterial peritonitis (SBP) carries 80% mortality
    
• Up to 30% yearly incidence of SBP in patients with ascites
  

• Mechanism:
  
  • Portal hypertension causes translocation of intestinal bacteria through edematous gut mucosa to the peritoneal cavity
    
  • Variceal bleeding increases the risk of SBP due to a compromised barrier between the GI tract and blood stream
    
  • Transient bacteremia with low serum complement
    
  • Decreased host defense mechanisms
    
  • Impaired activity of reticuloendothelial system phagocytosis and opsonization
    
  • Can also seed ascitic fluid via bacteremia from infections outside of the gut
    
• Usually seen in the setting of cirrhosis:
  
  • Rare in other conditions causing ascites (nephrotic syndrome or CHF)
    
• Predominant organisms:
  
  • 63% aerobic gram-negative (
    Escherichia coli
    ,
    Klebsiella
    , others)
    
  • 15% gram-positive (Streptococci)
    
  • 6–10% enterococci
    
  • <1% anaerobic
    
• Gram-positives account for 50% of cases in patients who are on prophylactic therapy with fluoroquinolones.
  

DIAGNOSIS

Up to 30% of patients with SBP have no signs or symptoms of infection.

• Abdominal pain: Diffuse, constant, often very mild
  
• Fever, chills
  
• Diarrhea from bacterial overgrowth
  
• Worsening ascites
  
• Altered mental status
  
• Fatigue, myalgias
  

• Fever is the most common sign:
  
  • A lower threshold for fever (>37.8°C or >100°F) is maintained for cirrhotic patients owing to baseline hypothermia
    
  • 80% of patients with SBP have fevers and chills
    
• Altered mental status
  
• Ascites
  
• Abdominal tenderness:
  
  • Development of a rigid abdomen may not occur because of the separation of visceral and parietal pleura due to ascites
    

• Paracentesis is the mainstay of diagnosis unless patient has peritoneal dialysis
  
• Coagulopathy does not have to be corrected before the procedure (except for platelets <20,000)
  
• Procedure:
  
  • Use ultrasound guidance when available
    
  • Location (with patient supine):
    
    • 3–5 cm cephalad and medial to anterosuperior iliac spine, lateral to the rectus sheath OR
      
    • 2 cm caudad to the umbilicus (ensure bladder emptying beforehand)
      
  • 40–50 mL should be aspirated, then change needles to avoid contamination:
    
    • 10 mL for each culture bottle
      
    • 10 mL for cell count, chemistries, Gram stain (lithium–heparin tube, EDTA tube, and sterile container)
      
  • Inoculate culture bottles with peritoneal fluid immediately at the bedside