Emergency department evaluation and treatment of back pain

Patients with back pain commonly present in the emergency department for evaluation and treatment. Because it is a common syndrome with a generally benign origin, the examiner may overlook markers of serious disease. This article reviews the important historical and physical factors to consider, with an emphasis on the red flags of serious disease. This article also reviews the management of acute lumbosacral strain, sciatica, and disc herniation, cauda equina syndrome and spinal cord compression, and back pain in the patient with a history of cancer.

Early recognition of spinal cord compression in cancer patients

Spinal cord compression is a relatively common complication of a number of malignant diseases. Back pain is the presenting symptom in more than 90% of cases. Early recognition and prompt treatment, while the patient can still walk, are the most important factors in preventing permanent and debilitating neurologic dysfunction.

Missed cervical spine fracture: chiropractic implications

OBJECTIVE

To discuss the case of a patient with an anterior compression fracture of the cervical spine, which had been overlooked on initial examination.

CLINICAL FEATURES

A 36-year-old man was seen at a chiropractic clinic 1 month after diving into the ocean and hitting his head on the ocean floor. He chipped a tooth but denied loss of consciousness. Initial medical examination in the emergency department did not include radiography, but an anti-inflammatory medication was prescribed. Radiographs taken at the chiropractic clinic 1 month later revealed an anterior compression fracture of the C7 vertebra, with migration of the fragment noted on flexion and extension views.

INTERVENTION AND OUTCOME

The patient was referred back to his medical doctor for further evaluation and management.He was instructed to wear a Philadelphia collar for 4 weeks. During this time period, he reported "shooting" pain and tingling from his neck into his arms. The patient reported resolution of his neck and arm symptoms at 2.5 months after injury. Follow-up radiographs at 6 months after injury revealed fusion of the fracture fragment with mild residual deformity. At that time, the patient began a course of chiropractic treatment.

CONCLUSION

After head trauma, it is essential to obtain a radiograph of the cervical spine to rule out fracture. Chiropractors should proceed with caution, regardless of any prior medical or ancillary evaluation, before commencing cervical spine manipulation after head and neck trauma.

Extraosseous extension of vertebral hemangioma, a rare cause of spinal cord compression

STUDY DESIGN

Case report.

OBJECTIVE

To illustrate a rare cause of thoracic spinal cord compression, its diagnosis, and its management.

SUMMARY OF BACKGROUND DATA

Asymptomatic vertebral hemangiomas are common, but extraosseous extension causing spinal cord compression with neurologic symptoms is rare, and few cases appear in the English-language literature.

METHOD

A previously asymptomatic 63-year-old man sought medical attention for acute back pain and thoracic myelopathy of 6 week's duration. Magnetic resonance imaging confirmed the presence of a mass in the T10 vertebral body with paravertebral and intracanalicular extension contributing to cord compression. Decompression and reconstructive surgery were performed and radiotherapy administered after surgery. Preoperative angiography was not performed because of the patient's rapidly progressive neurologic deterioration and the consideration that the differential diagnosis of vertebral hemangioma was less likely.

RESULTS

The diagnosis of benign capillary hemangioma was made histologically. Neurologic recovery was complete except for minor residual sensory changes in the legs. At follow-up 10 months after surgery the patient had returned to his usual active life and motor mower repairing business.

CONCLUSION

Extraosseous extension of vertebral hemangiomas is a rare cause of thoracic spinal cord compression. As such, the available data are derived from reports based on series involving only a small number of cases, rather than on results of randomized controlled trials. Those causing progressive neurologic symptoms should be surgically decompressed, with the specific procedure determined by the extent and site of the lesion. Preoperative angiography is recommended, but embolization is not always necessary or even possible. Postoperative radiotherapy is recommended when tumor removal is subtotal.

[Medullary compression in metastatic cancer]

Cancer patients with spinal cord compression may develop irreversible neurological deficit. The clinical picture implies back pain and subsequent neurological deficit. There is always a danger of rapid deterioration of the patient's condition. If spinal cord compression is suspected, the case is an emergency. MRI should be preferred in the diagnostic work-up, and corticosteroids be administered promptly. Radiation therapy or surgical treatment should be started as soon as possible. Patient outcome is related to the degree of neurological deficit at the start of treatment.

Brown-Sequard syndrome after management of vertebral hemangioma with intralesional alcohol. A case report

STUDY DESIGN

This report describes Brown-Sequard syndrome after intralesional injection of absolute alcohol into vertebral hemangioma.

OBJECTIVE

To discuss whether the described technique is safe in the management of vertebral hemangiomas.

SUMMARY OF BACKGROUND DATA

The management of vertebral hemangiomas remains controversial. There have been reports of successful management using intralesional absolute alcohol.

METHODS

The clinical and radiologic features of the reported complication are detailed.

RESULTS

Intralesional injection of absolute alcohol caused Brown-Sequard syndrome.

CONCLUSION

This case shows that intralesional alcohol injection cannot be considered a safe technique for management of vertebral hemangiomas with spinal cord compression.

The value of somatosensory- and motor-evoked potentials in predicting and monitoring the effect of therapy in spondylotic cervical myelopathy. Prospective randomized study

STUDY DESIGN

A 2-year follow-up prospective randomized electrophysiologic and clinical study of patients with spondylotic cervical myelopathy.

OBJECTIVE

To assess the value of somatosensory- and motor-evoked potentials in the evaluation and prediction of the effect of therapy.

SUMMARY OF BACKGROUND DATA

Previous studies have yielded conflicting data concerning the correlation between the changes in evoked potential parameters and the clinical postsurgical outcome in spondylotic cervical myelopathy.

METHODS

Sixty-one patients with magnetic resonance images suggesting spondylotic cervical cord compression and clinical signs of cervical myelopathy were divided into two groups according to the degree of clinical cervical cord involvement. The 49 patients with mild and moderate spondylotic cervical myelopathy were randomized into groups that underwent either surgical or conservative therapy. Patients were evaluated clinically and by the means of somatosensory- and motor-evoked potentials.

RESULTS

The clinical and evoked potential changes showed good correlation on the group level, but poor correlation intraindividually. There were no significant evoked potential and clinical group changes after 6 months and 2 years in the mild myelopathy group treated either surgically and conservatively, whereas patients with severe myelopathy displayed significant improvement in clinical and evoked potential parameters after surgery. In a subgroup of patients, the isolated segmental medullar N13 abnormality could potentially predict favorable postsurgical clinical outcome.

CONCLUSIONS

Longitudinal evoked potentials showed limited use for evaluating the results of therapy in an individual patient. They could be useful in the group assessment of therapy results and in labeling a subgroup of patients with potentially favorable postsurgical outcome.

Management of pain and spinal cord compression in patients with advanced cancer. ACP-ASIM End-of-life Care Consensus Panel. American College of Physicians-American Society of Internal Medicine

General internists often care for patients with advanced cancer. These patients have substantial morbidity caused by moderate to severe pain and by spinal cord compression. With appropriate multidisciplinary care, pain can be controlled in 90% of patients who have advanced malignant conditions, and 90% of ambulatory patients with spinal cord compression can remain ambulatory. Guidelines have been developed for assessing and managing patients with these problems, but implementing the guidelines can be problematic for physicians who infrequently need to use them. This paper traces the last year of life of Mr. Simmons, a hypothetical patient who is dying of refractory prostate cancer. Mr. Simmons and his family interact with professionals from various disciplines during this year. Advance care planning is completed and activated. Practical suggestions are offered for assessment and treatment of all aspects of his pain, including its physical, psychological, social, and spiritual dimensions. The methods of pain relief used or discussed include nonpharmacologic techniques, nonopioid analgesics, opioids, adjuvant medications, radiation therapy, and radiopharmaceutical agents. Overcoming resistance to taking opioids; initiating, titrating, and changing opioid routes and agents; and preventing or relieving the side effects they induce are also covered. Data on assessment and treatment of spinal cord compression are reviewed. Physicians can use the techniques described to more readily implement existing guidelines and provide comfort and optimize quality of life for patients with advanced cancer.

Balloon device for experimental graded spinal cord compression in the rat

We have developed a balloon device that creates reproducible graded compression of the rat spinal cord. It uses a modified Camino intracranial pressure monitor bolt with a small latex balloon attached to the tip. The device is affixed to the spinous processes of two cervicothoracic vertebrae and positioned directly over an exposed segment of spinal cord. Ten compression balloons were tested and revealed reproducible pressure transmission at expansion volumes from 0.12 to 0.34 cc. Reversible graded spinal cord compression was verified by monitoring cortical somatosensory and motor evoked potentials before, during, and after cord compression. The pathophysiologic changes occurring with graded compression and the effect of therapeutic interventions can be studied in a rat model.

Pathology of the spinal cord damaged by ossification of the posterior longitudinal ligament associated with spinal cord injury

A 63-year-old male became quadriplegic after spinal injury associated with ossification of the posterior longitudinal ligament of the cervical spine and died 4 years later. A postmortem examination of the cervical spinal cord showed various unfavorable pathological changes accounting for severe myelopathy.

Neurological complications of neurofibromatosis type 1 in adulthood

Neurofibromatosis type 1 (NF1) is a genetic disease with a wide range of neurological manifestations. To examine these, and to evaluate neurological morbidity in adulthood of patients with NF1, we studied a hospital-based series of 158 patients that included 138 adult patients aged >18 years and 20 children. NF1 evaluation included a multidisciplinary clinical and a clinically oriented radiological investigation. Neurological events occurring during childhood (in both children and adults of the series) and adulthood were recorded. One or several neurological manifestations have been observed in 55% of patients (adults and children) (n = 87). These included: headache (28 patients); hydrocephalus (7); epilepsy (5); lacunar stroke (1); white matter disease (1); intraspinal neurofibroma (3); facial palsy (1); radiculopathy (5); and polyneuropathy (2). Tumours included: optic pathway tumours (20); meningioma (2); cerebral glioma (3); and malignant peripheral nerve sheath tumours (6). Life-threatening complications were observed in five adults and included four malignant peripheral nerve sheath tumours and one meningioma. Pain was the leading symptom in 11 adults and was related to malignant peripheral nerve sheath tumours, complications of intraspinal neurofibromas, subcutaneous neurofibromas and peripheral nerve neurofibromas. NF1 in adults was not associated with other disabling or life-threatening neurological complications. Symptomatic optic pathway tumours, cerebral gliomas, symptomatic aqueductal stenosis and spinal compression due to intraspinal NF were observed exclusively during childhood. In this series, the predominant neurological features of adults with NF1 were chronic pain and malignant peripheral nerve sheath tumours.

Successful conservative treatment of rheumatoid subaxial subluxation resulting in improvement of myelopathy, reduction of subluxation, and stabilisation of the cervical spine. A report of two cases

OBJECTIVE

To report the efficacy of conservative treatment with cervical traction and immobilisation with a Halo vest, in two consecutive rheumatoid arthritis patients with progressive cervical myelopathy caused by subaxial subluxation.

METHODS

Description of neurological symptoms and signs and findings in plain radiography (PR) and magnetic resonance imaging (MRI) of the cervical spine before and after treatment of the subaxial subluxation by traction and immobilisation with a Halo vest during four months.

RESULTS

During four months of traction and immobilisation neurological examination showed a considerable improvement of the signs and symptoms of cervical myelopathy. Afterwards PR and MRI of the cervical spine showed reduction of the subaxial subluxation. Eventually firm stabilisation was obtained in both patients without surgery of the cervical spine.

CONCLUSION

Cervical traction and immobilisation with a Halo vest can be considered as an independent conservative treatment in rheumatoid arthritis patients with cervical myelopathy caused by subaxial subluxation.

Improved recovery after spinal cord trauma in ICAM-1 and P-selectin knockout mice

Traumatic spinal cord injury is followed by infiltration of leukocytes, influenced by endothelial adhesion molecules such as ICAM-1 and P-selectin. In order to evaluate the pathogenetical role of these molecules, wild-type mice and mice lacking ICAM-1 and P-selectin were subjected to an experimental spinal cord compression of two degrees of severity. Hind limb motor function decreased after injury in all animals but the groups of injured ICAM-1/P-selectin knockout animals had a better functional outcome during the entire observation period of 14 days. This difference was statistically significant on day 1. Our results indicate that adhesion molecules influence the functional outcome after spinal cord injury in a negative way and may be a target for future therapy of neurotrauma.

Management of patients with vertebral compression fractures

Osteoporosis is a disease of low bone mass that may not manifest until a patient has a fracture. Hip fracture is the most devastating, but vertebral fracture is the most common, occurring in 25% of women over 50 years of age and 40% of those age 80-85 years. Although 60% of vertebral fractures are clinically silent, they are easily diagnosed radiographically. They are associated with height loss, deformity, impaired mobility, and pain. Patients should be evaluated for the cause of both the fracture and osteoporosis. Therapy includes education about the disease, an exercise program, and advice about tailoring routine activities. Pharmacotherapy includes annual influenza vaccines, and daily calcium (1200-1500 mg elemental calcium/day) and vitamin D (400-800 IU/day) supplements. New antiresorptive agents alendronate, hormone replacement therapy, and salmon calcitonin should be offered to all patients as they reduce fracture rates.

Metastatic spinal cord compression: diagnostic delay, treatment, and outcome

BACKGROUND

Metastatic spinal cord compression (MSCC) is a disabling complication of malignant disease. The aim of this study was to estimate diagnostic delay, treatment outcome, and prognostic factors in patients with MSCC.

MATERIAL AND METHODS

In 86 patients treated for MSCC at our institution, the median age was 65 years and there was a preponderance of males (73%). The median observation period was 39 months. Carcinoma of the prostate, lung, breast, and kidney constituted 66% of the primary malignancies. Prior to treatment, 34% had grade 1, 53% grade 2, and 13% grade 3 paresis. 33% underwent surgical laminectomy with postoperative radiotherapy (combined therapy), while 67% were irradiated only.

RESULTS

Median time from the start of symptoms to the first doctor contact was 1 day, and to hospital admission or treatment start 6 days and 8 days. The pre-treatment grade of paresis, preservation of gait function, and primary tumour histology were strong predictors for treatment response. Pain relief, reported by 82% of assessable patients, correlated to treatment response grade. Median survival from treatment start was 4.1 months. Survival corresponded positively to preserved gait function at admission, to treatment response grade, and to the employment of combined therapy. Primary tumour histology was an important predictor as breast cancer and prostate cancer had 3 to 6-fold longer survival compared to lung cancer patients.

CONCLUSION

Prolonged survival in a minority of the patients signified the importance of optimal treatment. To settle whether radiotherapy alone is the optimal treatment in all MSCC patients, a randomised trial is warranted.

Closed reduction of bilateral locked facets of the cervical spine under general anaesthesia

BACKGROUND

Bilateral facet interlocking of the cervical spine is a relatively uncommon type of cervical spinal injury. It is frequently associated with devastating neurological symptoms and signs. Early reduction of the locked facets is thought to be critical in preventing progressive secondary spinal cord injury. Whereas skull tong traction remains our primary option for closed reduction of bilateral locked facets of the cervical spine, it is not always successful, even with heavy traction weights. Other more aggressive measures may occasionally be required. The authors report their experience in reducing bilateral locked facets of the cervical spine by manual closed reduction.

METHODS

This small series consists of six cases of cervical spinal injury with bilateral locked facets in which manual closed reduction under general anaethesia and muscle relaxation was used. Three of them presented with complete quadriplegia (Frankel class A). One case presented with incomplete but severe neurological deficits (Frankel class B). After unsuccessful closed reduction with skull traction, these patients were treated by manual closed reduction under general anaesthesia and muscle relaxation, followed by anterior discectomy, interbody fusion and stabilization.

RESULTS

All cases made neurological improvement after the procedures. Even in cases with initial severe neurological deficits, the recovery was remarkable. The recovery was dramatic in two cases. Case 1 improved from Frankel class B to E; and Case 5 from Frankel class A to D. No case deteriorated neurologically after the procedures. Pneumonia occurred in Case 3; and stress ulcer accompanied by haemorrhage was noted in Case 4. None of these complications was directly related to the procedures.

CONCLUSION

The potential for improvement of neurological function following early and successful reduction and fixation of the dislocated spine is emphasized. With meticulous techniques, manual closed reduction may be an effective alternative to skull tong traction when the latter fails.

[Spinal cord injury in multiple myeloma]

Myelomic spinal cord damage may be a result of both its compression and vascular disorders (squeezing of an artery, disorders of venous outflow). Diagnosis is based on evaluation of the following signs: normochromic anemia; increase of ESR, total protein and calcium levels; discovery of M-gradient in protein fractions of gamma-zone; multiple regions of destruction in spondylogramme. In doubtful cases magneto-resonance and computer tomography were the most informative. Highly effective was therapy with intensive chemoprogramme including either a range of preparations (alkeran, BGNU, cyclophosphan, adriblastina, prednisolon) or a combination of polychemotherapy with irradiation. The operation was indicated in both insufficiency of conservative therapy and increasing of the symptoms of the damage.

[Spinal cord compression secondary to epidural extramedullary hematopoiesis in thalassemia: a clinical case and review of literature]

INTRODUCTION

Extramedullary hematopoiesis generally occurs in a variety of hematological disorders where the normal functioning of the blood forming organs is disturbed. It is a common manifestation in thalassemia where it occurs as a compensatory phenomenon in order to combat long standing anemia. Spinal cord compression as a consequence of extramedullary hematopoiesis in the intraspinal epidural space is an extremely rare complication, though this complication has been reported more commonly in thalassemia.

CLINICAL CASE

A case of spinal cord compression due to extramedullary hematopoiesis in a patient with thalassemia is reported. The patient was successfully treated with radiation therapy and blood transfusions and he made a complete clinical recovery. Development. The literature is reviewed and the efficacy of several treatments such as surgery, radiotherapy and blood transfusion therapy is discussed. Until recently surgical decompression followed by radiation therapy remained the recommended treatment. Hematopoietic tissue is particularly sensitive to the ionizing radiation and low-dose radiotherapy is enough to relieve the spinal cord compression. Blood transfusion therapy may be diagnostically and therapeutically useful in the management of this entity.

CONCLUSIONS

A prompt recognition of the syndrome and early treatment with radiotherapy and blood transfusion therapy is recommended to prevent irreversible damage to the spinal cord. Surgery may be only considered in the event of progressive neurological deficit despite of radiotherapy or blood transfusion therapy.

Trauma in congenital atlanto-axial dislocation

Congenital atlanto-axial dislocation (AAD) usually presents with chronically progressive compression of the cervico-medullary junction. However, even a minor trauma can cause acute compression with development of quadruplegia and respiratory impairment. At times these may be transient, or trauma may aggravate the compression and lead to progressive quadriplegia. Of 60 children seen with congenital AAD, in 15 it had been associated with trauma. Nine of these 15 AADs were of the mobile variety, and 6 of the fixed variety with odontoid invagination. In 6 children with mobile and 2 with fixed AAD, trauma led to an acute manifestation with quadriplegia. Three of the children also experienced respiratory distress and needed ventilatory support. All 15 were initially treated with skull traction. Once the condition was stabilised, those with the mobile variety underwent fixation in a reduced position and grafting. One of the children with respiratory distress died within 2 days of admission. In 4 of them, sublaminar wiring between C1 and C2 was carried out, and in 3 others wiring between occiput and base of spinous process of C2 was performed. In 1 case a Hartshill loop was used. Among the children with fixed AAD, reduction of the odontoid invagination was obtained in 2, and they underwent fusion. In 4 cases with unsatisfactory reduction, posterior decompression of the foramen magnum and the fused posterior arch of the atlas was performed. The results depended on the degree of neurological deficit in each child.

Effect of hypertonic saline on leukocyte activity after spinal cord injury

STUDY DESIGN

The effect of intravenous administration of hypertonic saline on leukocyte adhesion after compression injury of the spinal cord was evaluated.

OBJECTIVES

To investigate changes in leukocyte adhesion after spinal cord injury and to evaluate the effect of hypertonic saline on this process.

SUMMARY OF BACKGROUND DATA

Leukocytes have been thought to exacerbate tissue injury after ischemia-reperfusion. Downregulating and reducing the number of circulating leukocytes has attenuated tissue damage in various models of cerebral ischemia. Recently, investigators have reported that leukocytes exacerbate injury in the spinal cord after trauma. Other recent findings have indicated that hypertonic saline may play a role in decreasing leukocyte adhesion and activation.

METHODS

Sprague-Dawley rats were anesthetized, and a C3-C5 laminectomy was performed. Injury was caused by 35 g of compression applied to the cord for 10 minutes. Animals were divided into three groups: sham treated, untreated, and treated. The treated animals received 7.5% hypertonic saline (5 mL/kg, intravenously) 5 minutes after the injury. Sticking leukocytes and shear rate were measured using fluorescence microscopy.

RESULTS

Administration of 7.5% hypertonic saline after injury significantly decreased the number of sticking leukocytes in the venules and arterioles. Shear rate was unchanged between the groups.

CONCLUSIONS

The results show that an increase in leukocyte adhesion after a compressive injury is attenuated by the administration of 7.5% hypertonic saline. The decrease in adhesion cannot be attributed to changes in the shearing forces, because no significant change was observed in the shear rate. Hypertonic saline may interfere with leukocytes directly by interfering with their ability to swell and thus may prevent activation.

Cervical spinal cord compression caused by cryptococcosis in a dog: successful treatment with surgery and fluconazole

A six-year-old, male Doberman pinscher was presented for acute onset of upper motor neuron tetraparesis. An extradural compressive lesion compatible with intervertebral disk rupture at the sixth to seventh cervical (C6-C7) disk space was evident on myelography. A large, gelatinous mass of pure cryptococcal organisms causing spinal cord compression was identified upon exploratory surgery. Removal of the mass caused relief of clinical signs. No evidence of involvement of other organ systems was found; however, serum and cerebrospinal fluid titers were positive for cryptococcal infection. The dog was treated with fluconazole (5.5 mg/kg body weight, per os sid) until serum titers for cryptococcal infection were negative at seven months postsurgery. To the authors' knowledge, this is the only report of a dog with cryptococcosis treated successfully using fluconazole as a sole agent.

Systemic hypothermia after spinal cord compression injury in the rat: does recorded temperature in accessible organs reflect the intramedullary temperature in the spinal cord?

This article addresses one basic issue regarding the use of systemic hypothermia in the acute management of spinal cord injury, namely, how to interpret temperature recordings in accessible organs such as the rectum or esophagus with reference to the spinal cord temperature. Thirty-six rats, divided into six groups, were randomized to laminectomy or to severe spinal cord compression trauma, and were further randomized to either a cooling/rewarming procedure or continuous normothermia (esophageal temperature 38 degrees C) for 90 min. The first procedure comprised normothermia during the surgical procedure, followed by lowering of the esophageal temperature from 38 degrees C to 30 degrees C (the hypothermic level), a 20-min steady-state period at 30 degrees C, rewarming to 38 degrees C, and finally a 20-min steady-state period at 38 degrees C. The esophageal, rectal, and epidural temperatures were recorded in all animals. The intramedullary temperature was also recorded invasively in four of the six groups. We conclude that the esophageal temperature is safe and easy to record and, in our setting, reflects the epidural temperature. The differences registrated may reflect a true deviation of the intramedullary temperature due to initial environmental exposure and secondary injury processes. Our results indicate that the esophageal temperature exceeds the intramedullary temperature during the initial recording and final steady state following rewarming, but not during the most crucial part of the experiment, the hypothermic period. The core temperature measured in the esophagus can therefore be used to evaluate the intramedullary temperature during alterations of the systemic temperature and during hypothermic periods.