Risk Factors for Serious Underlying Pathology in Adult Emergency Department Nontraumatic Low Back Pain Patients

Utilisation and experience of emergency medical services by patients with back pain: A scoping review

BACKGROUND

Back pain is recognised as a common reason for people to access emergency medical services (EMS). EMS focus on identifying and treating serious and life-threatening conditions. Back pain frequently has a non-specific cause, however back pain is also a symptom for potentially serious pathology best suited for management by EMS.

OBJECTIVES

This scoping review explores how and why patients with back pain access EMS, the care provided, and patients' and clinicians' perceptions of EMS.

METHODS

The established methodology advocated by the Joanna Briggs Institute was followed. Literature was identified via a comprehensive search of six databases as well as grey literature searching. Data was extracted to form a narrative review supported by summary tables and figures.

RESULTS

The review included 144 papers across the last 36 years, with half the papers published since 2018, the majority from the USA and Australia. Rates of back pain presentation range from 1 to 9% depending on the definition used, with the rate of serious pathology higher than in primary care. Patients present due to concerns about their condition, positive perceptions of the care provided by EMS and difficulty in accessing primary care. Imaging and opioids are widely used, blood markers may aid diagnosis of serious pathology, whilst physiotherapists in Emergency Departments may support management of patients without serious pathology.

CONCLUSIONS

Back pain is a common reason for EMS presentation. Whilst non-specific back pain is the most common diagnosis further research to support the recognition and care of serious cases would be beneficial.

Diagnosis Value of Patient Evaluation Components Applicable in Primary Care Settings for the Diagnosis of Low Back Pain: A Scoping Review of Systematic Reviews

Low back pain ranks as the leading cause of years lived with disability worldwide. Although best practice guidelines share a consistent diagnostic approach for the evaluation of patients with low back pain, confusion remains as to what extent patient history and physical examination findings can inform management strategies. The aim of this study was to summarize evidence investigating the diagnostic value of patient evaluation components applicable in primary care settings for the diagnosis of low back pain. To this end, peer-reviewed systematic reviews were searched in MEDLINE, CINAHL, PsycINFO and Cochrane databases from 1 January 2000 to 10 April 2023. Paired reviewers independently reviewed all citations and articles using a two-phase screening process and independently extracted the data. Of the 2077 articles identified, 27 met the inclusion criteria, focusing on the diagnosis of lumbar spinal stenosis, radicular syndrome, non- specific low back pain and specific low back pain. Most patient evaluation components lack diagnostic accuracy for the diagnosis of low back pain when considered in isolation. Further research is needed to develop evidence-based and standardized evaluation procedures, especially for primary care settings where evidence is still scarce.

Do patients with acute low back pain in emergency departments have more severe symptoms than those in general practice? A systematic review with meta-analysis

INTRODUCTION

There is a common belief that patients presenting to emergency departments have more severe pain levels and functional limitations than those in general practice. The aim of this systematic review was to compare pain and disability levels of patients with acute low back pain presenting to general practice versus those presenting to emergency departments.

METHODS

Electronic searches were conducted in MEDLINE, EMBASE and CINAHL from inception to February 2019. Observational studies including patients with acute non-specific low back pain presenting to emergency departments and/or general practice were eligible. Pain and/or disability scores expressed on a 0-100 scale were the primary outcomes. Risk of bias was evaluated using a validated tool for observational studies and the overall quality of evidence was assessed using GRADE. Meta-analysis using random effects and meta-regression were used to test for differences between the two settings.

RESULTS

We included 12 records reporting results for 10 unique studies with a total of 6,999 participants from general practice (n = 6) and emergency departments (n = 4). There was low quality evidence (downgraded for indirectness and inconsistency) that patients presenting to emergency departments had higher pain scores than those in general practice with a mean difference of 17.3 points (95%CI: 8.8 to 25.9 on a 0-100 scale). Similarly, there was low quality evidence (downgraded for indirectness and inconsistency) that patients presenting to emergency departments had higher disability scores than those in general practice (mean difference: 21.7, 95%CI: 4.6 to 38.7 on a 0-100 scale).

CONCLUSION

Patients with acute non-specific low back pain presenting to emergency departments may report higher levels of pain and disability than those seen in general practice.

PROSPERO REGISTRATION NUMBER

CRD42017076806.

The diagnostic value of Red Flags in thoracolumbar pain: a systematic review

PURPOSE

Red Flags (RFs) are signs and symptoms related to the screening of serious underlying pathologies mimicking a musculoskeletal pain. The current literature wonders about the usefulness of RFs, due to high false-positive rates and low diagnostic accuracy. The aims of this systematic review are: (a) to identify and (b) to evaluate the most important RFs that could be found by a health care professional during the assessment of patients with low and upper back pain (named as thoracolumbar pain (TLP)) to screen serious pathologies.

MATERIALS AND METHODS

A systematic review of the literature was conducted. Searches were performed on seven databases (Pubmed, Web of Science, Cochrane Library, Pedro, Scielo, CINAHL, and Google Scholar) between March 2019 and June 2020, using a search string which included synonyms of low back pain (LBP), chest pain (CP), differential diagnosis, RF, and serious disease. Only observational studies enrolling patients with LBP or CP were included. Risk of bias was assessed with the Newcastle Ottawa Scale and inter-rater agreement between authors for full-text selection was evaluated with Cohen's Kappa. Where possible the diagnostic accuracy was recorded for sensitivity (Sn), specificity (Sp), and positive/negative likelihood ratio (LR+/LR-).

RESULTS

Forty full-texts were included. Most of the included observational studies were judged as low risk of bias, and Cohen's Kappa was good (=0.78). The identified RFs were: advanced age; neurological signs; history of trauma; malignancy; female gender; corticosteroids use; night pain; unintentional weight loss; bladder or bowel dysfunction; loss of anal sphincter tone; saddle anaesthesia; constant pain; recent infection; family or personal history of heart or pulmonary diseases; dyspnoea; fever; postprandial CP; typical reflux symptoms; haemoptysis; sweating; pain radiated to upper limbs; hypotension; retrosternal pain; exertional pain; diaphoresis; and tachycardia. The diagnostic accuracy of RFs as self-contained screening tool was low, while the combination of multiple RFs showed to increase the probability to identify serious pathologies.

CONCLUSIONS

Despite the use of single RF should not be recommended for the screening process in clinical practice, the combination of multiple RFs to enhance diagnostic accuracy is promising. Moreover, the identified RFs could be a baseline to develop a screening tool for patients with TLP.Implications for rehabilitationDifferential diagnosis and screening for referral are mandatory skills for each healthcare professional in direct access clinical settings, and should be the primary step for an appropriate management of a patient with signs and symptoms mimicking serious pathologies in thoracolumbar region.Clinical reasoning and decision-making processes are essential throughout all phases of a patient's pathway of care. By which, the use of single Red Flag (RF) as a self-contained screening tool should not be recommended. The combination of multiple RFs promises to increase diagnostic accuracy and could grow into an excellent screening tool for thoracolumbar pain.

Back pain "red flags": which are most predictive of serious pathology in the Emergency Department?

PURPOSE

To determine the frequency of red flag signs and symptoms in patients presenting with back pain to the Emergency Department (ED) and association with serious pathologies and investigations performed.

METHODS

This retrospective observational study evaluated consecutive patients presenting with back pain to a Melbourne ED over a 14-month period. Data regarding red flags, patient characteristics, ED-initiated investigations, and diagnoses were extracted from medical records. Prevalence of each red flag and sensitivity, specificity, and likelihood ratios for diagnosing serious spinal or non-spinal pathology were calculated.

RESULTS

Analysis was undertaken on 1000 eligible participants with back pain. 69% had red flags. Participants were categorised into diagnostic groups: musculoskeletal (80.6%), serious spinal (3.3%), and serious non-spinal (14.6%) pathologies. A number of red flags had positive likelihood ratios (LR) > 5, indicating a higher probability of serious pathology (spinal/non-spinal) including fever (LR + 68.8), tuberculosis history (LR + 13.8), known nephrolithiasis/abdominal aortic aneurysm (LR + 10.2), unexplained weight-loss (LR + 9.2), writhing in pain (LR + 6.9), urinary symptoms (LR + 5.4), and flank pain (LR + 5.2). Red flags with positive LR > 5 indicating a higher probability of serious spinal pathology were saddle anaesthesia (LR + 11.0), tuberculosis history (LR + 9.8), intravenous drug-use (LR + 6.9), acute-onset urinary retention (LR + 6.4), and anal tone loss (LR + 6.3).

CONCLUSION

The majority of this study cohort had back pain of benign cause. Some red flags were associated with greater risk of serious pathology, others were not. Further evidence regarding red flags and their association with serious pathology is required, to better inform clinical guidelines.

What is the incidence of cauda equina syndrome? A systematic review

OBJECTIVE

Cauda equina syndrome (CES) is a surgical emergency requiring timely operative intervention to prevent symptom progression. Accurately establishing the incidence of CES is required to inform healthcare service design and delivery, including out-of-hours imaging arrangements.

METHODS

A systematic literature search of MEDLINE, EMBASE, and Scopus was undertaken to identify original studies stating the incidence of CES, and the estimates were combined in a meta-analysis as described in the protocol registered with PROSPERO (registration no. CRD42017065865) and reported using the PRISMA guidelines.

RESULTS

A total of 1281 studies were identified, and 26 studies were included in the review. Data about CES incidence were available from 3 different populations: asymptomatic community populations, patients with nontraumatic low-back pain, and patients presenting as an emergency with suspected CES. The incidence of CES was 0.3-0.5 per 100,000 per year in 2 asymptomatic community populations, 0.6 per 100,000 per year in an asymptomatic adult population, and 7 per 100,000 per year in an asymptomatic working-age population. CES occurred in 0.08% of those with low-back pain presenting to primary care in 1 study, and a combined estimate of 0.27% was calculated for 4 studies of those with low-back pain presenting to secondary care. Across 18 studies of adults with suspected CES, 19% had radiological and clinical CES. Difficulties in comparison between studies resulted from the heterogeneous definitions of CES and lack of separation of more advanced CES with retention, which is unlikely to be reversible. In the studies of patients with suspected CES, the small sample size, the high number of single-center studies (18/18), the high number of studies from the United Kingdom (17/18), the retrospective nature of the studies, and the high number of abstracts rather than full texts (9/18) reduced the quality of the data.

CONCLUSIONS

From current studies, it appears that CES occurs infrequently in asymptomatic community populations and in only 19% of those presenting with symptoms. Determining accurate incidence figures and designing a bespoke service for investigation of patients with suspected CES would require a consensus clinical and radiological definition of CES and international multisite studies of patient pathways of investigation and management.

Healthcare utilization and costs for spinal conditions in Ontario, Canada - opportunities for funding high-value care: a retrospective cohort study

BACKGROUND CONTEXT

An important step in improving spinal care is understanding how current health-care resources and associated cost are being utilized and distributed across a health-care system.

PURPOSE

Our objective was to examine the magnitude and distribution of direct health care costs for spinal conditions across physician type and hospital setting.

DESIGN/SETTING

Cross-sectional analysis of administrative health data for the fiscal year 2013-2014 from the province of Ontario, Canada.

PATIENT SAMPLE

Adult population aged 18+ years (N=10,841,302).

OUTCOME MEASURES

Person visit rates and total number of people and visits by specific care settings were calculated for all spinal conditions as well as stratified by nontrauma and trauma-related conditions. Variation in rates by age and sex was examined. The proportion of patients seeing physicians of different specialties was calculated for each condition grouping. Direct medical costs were estimated and their percentage distribution by care setting calculated for nontrauma and trauma-related conditions. Additionally, costs for spinal imaging overall and stratified by type of scan were determined.

METHODS

Administrative health databases were analyzed, including data on physician services, emergency department visits, and hospitalizations. ICD-9 and -10 diagnostic codes were used to identify nontraumatic (degenerative or inflammatory) and traumatic spinal disorders. A validated algorithm was used to estimate direct medical costs.

RESULTS

Overall, 822,000 adult Ontarians (7.6%) made 1.6 million outpatient physician visits for spinal conditions; the majority (1.1 million) of these visits were for nontrauma conditions. Approximately, 86% of outpatient visits were in primary care. Emergency Department (ED) visits for nontrauma spinal conditions (130,000 out of 156,000 ED visits) accounted for 2.8% of all ED visits in the province. Total costs for spine-related care were $264 million (CDN) with 64% of costs due to nontrauma conditions. For these nontrauma conditions, ED visits cost $28 million for 130,000 visits ($215 per visit). For $32 million spent in primary care, 890,000 visits were made ($36 per visit). Spine imaging costs were $66.5 million, yielding a combined total of $330 million in health care spending for spinal conditions.

CONCLUSIONS

Spinal conditions place a large and costly burden on the health-care system. The disproportionate annual cost associated with ED visits represents a potential opportunity to redirect costs to fund more clinically and cost-effective models of care for nontraumatic spinal conditions.

Profile of Patients With Acute Low Back Pain Who Sought Emergency Departments: A Cross-sectional Study

STUDY DESIGN

A cross-sectional study.

OBJECTIVE

The aim of this study is to describe the profile of patients with acute low back pain (LBP) who sought emergency departments (EDs) in Brazilian public hospitals. We also described the profile of these patients according to the STarT Back Screening Tool (SBST).

SUMMARY OF BACKGROUND DATA

LBP is the most common musculoskeletal condition worldwide and is one of the main complaints in EDs. There is a lack of evidence describing the profile of these patients from low- to middle-income countries.

METHODS

This is a cross-sectional study involving patients with a new episode of nonspecific acute LBP that was conducted between August 2014 and August 2016. Variables related to clinical, psychological, sociodemographic and work status characteristics were investigated through structured, in-person oral questionnaire.

RESULTS

A total of 600 patients were included in the study. The majority of the patients were women (58%), with a median of eight points on pain intensity (measured on an 11-point scale) and 17 points on disability (measured on a 24-item questionnaire). With regards to the SBST evaluation, 295 (49.2%) patients were classified as being at high risk of developing an unfavorable prognosis with a median pain intensity of nine points on pain intensity, 20 points on disability, and seven points on depression (measured on an 11-point scale). Despite this, the majority of the patients (74%) continued working normally without interference from LBP.

CONCLUSION

Identifying the profile of patients seeking care in EDs can help to define effective management for LBP in low- and middle-income countries. Patients with nonspecific acute LBP who seek EDs in Brazil present high levels of pain intensity and disability. Most patients were classified as having a high risk of developing an unfavorable prognosis.

LEVEL OF EVIDENCE

2.

Low Back Pain in the Emergency Department: Prevalence of Serious Spinal Pathologies and Diagnostic Accuracy of Red Flags

BACKGROUND

Very little evidence is available on the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting to the emergency department (ED). This systematic review aims to investigate the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting with low back pain to the ED.

METHODS

We systematically searched MEDLINE, PUBMED, EMBASE, Cochrane Library, and SCOPUS from inception to January 2019. Two reviewers independently reviewed the references and evaluated methodological quality.

RESULTS

We analyzed 22 studies with a total of 41,320 patients. The prevalence of any requiring immediate/urgent treatment was 2.5%-5.1% in prospective and 0.7%-7.4% in retrospective studies (0.0%-7.2% for vertebral fractures, 0.0%-2.1% for spinal cancer, 0.0%-1.9% for infectious disorders, 0.1%-1.9% for pathologies with spinal cord/cauda equina compression, 0.0%-0.9% for vascular pathologies). Examples of red flags which increased the likelihood for a serious condition were suspicion or history of cancer (spinal cancer); intravenous drug use, indwelling vascular catheter, and other infection site (epidural abscess).

CONCLUSION

We found a higher prevalence of serious spinal pathologies in the ED compared to the reported prevalence in primary care settings. As the diagnostic accuracy of most red flags was reported only by a single study, further validation in high-quality prospective studies is needed.

Management of low back pain in Australian emergency departments

Background

To describe the diagnoses of people who present to the emergency department (ED) with low back pain (LBP), the proportion of people with a lumbar spine condition who arrived by ambulance, received imaging, opioids and were admitted to hospital; and to explore factors associated with these four outcomes.

Methods

In this retrospective study, we analysed electronic medical records for all adults presenting with LBP at three Australian EDs from January 2016 to June 2018. Outcomes included discharge diagnoses and key aspects of care (ambulance transport, lumbar spine imaging, provision of opioids, admission). We explored factors associated with these care outcomes using multilevel mixed-effects logistic regression models and reported data as ORs.

Results

There were 14 024 presentations with a ‘visit reason’ for low back pain, of which 6393 (45.6%) had a diagnosis of a lumbar spine condition. Of these, 31.4% arrived by ambulance, 23.6% received lumbar imaging, 69.6% received opioids and 17.6% were admitted to hospital. Older patients (OR 1.79, 95% CI 1.56 to 2.04) were more likely to be imaged. Opioids were less used during working hours (OR 0.81, 95% CI 0.67 to 0.98) and in patients with non-serious LBP compared with patients with serious spinal pathology (OR 1.65, 95% CI 1.07 to 2.55). Hospital admission was more likely to occur during working hours (OR 1.74, 95% CI 1.48 to 2.05) and for those who arrived by ambulance (OR 2.98, 95% CI 2.53 to 3.51).

Conclusion

Many ED presentations of LBP were not due to a lumbar spine condition. Of those that were, we noted relatively high rates of lumbar imaging, opioid use and hospital admission.

The prevalence of low back pain in the emergency department: a descriptive study set in the Charles V. Keating Emergency and Trauma Centre, Halifax, Nova Scotia, Canada

Background

While low back pain is a common presenting complaint in the emergency department, current estimates from Canada are limited. Furthermore, existing estimates do not clearly define low back pain. As such, our main objective was to estimate prevalence rates of low back pain in a large Nova Scotian emergency department using various definitions, and to describe characteristics of individuals included in these groups. An additional objective was to explore trends in low back pain prevalence in our emergency department over time.

Methods

We conducted a cross sectional analysis using six years of administrative data from our local emergency setting. We first calculated the prevalence and patient characteristics for individuals presenting with any complaint of back pain, and for groups diagnosed with different types of low back pain. We explored prevalence over time by analyzing presentation trends by month, day of the week and hour of the day.

Results

The prevalence of patients presenting to the emergency department with a complaint of back pain was 3.17%. Individuals diagnosed with non-specific/mechanical low back pain with no potential nerve root involvement made up 60.8% of all back pain presentations. Persons diagnosed with non-specific/mechanical low back pain with potential nerve root involvement made up 6.7% of presentation and the low back pain attributed to secondary factors accounted for 9.9% of back pain presentations. We found a linear increase in presentations for low back pain over the study period.

Conclusion

This is the first multi-year analysis assessing the prevalence of low back pain in a Canadian emergency department. Back pain is a common presenting complaint in our local emergency department, with most of these persons receiving a diagnosis of non-specific/mechanical low back pain with no potential nerve root involvement. Future research should concentrate on understanding the management of low back pain in this setting, to ensure this is the proper setting to manage this common condition.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2237-x) contains supplementary material, which is available to authorized users.

Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review

Clinicians do not want to miss underlying serious pathology, but it is still unclear which red flags are relevant. We aimed to evaluate the origin and evidence on diagnostic accuracy of red flags for malignancy for management of low back pain (LBP) in primary care. We performed a comprehensive overview and searched the literature using snowballing techniques and reference checking for evidence on red flags endorsed in clinical guidelines for identifying patients with higher likelihood of malignancy. We selected studies including people with LBP without any restriction on study design. We extracted data on prevalence and diagnostic accuracy. Furthermore, we assessed the methodological quality of studies evaluating diagnostic accuracy. We identified 13 red flags endorsed in a total of 16 guidelines and 2 extra red flags not endorsed in any guideline. We included 33 publications varying from systematic reviews to case reports. The origin of many red flags was unclear or was sourced from case reports. The incidence of malignancy in patients presenting with LBP in primary care varied between 0% and 0.7%. Seven studies provided diagnostic accuracy data on red flags. We found 5 red flags with accuracy data from 2 or more studies, with 2 ("history of malignancy" and "strong clinical suspicion") considered informative. In conclusion, the origin and diagnostic accuracy of many red flags endorsed in guidelines are unclear. A "history of malignancy" and "strong clinical suspicion" are the only red flags with empirical evidence of acceptably high diagnostic accuracy.

Prevalence of low back pain in emergency settings: a systematic review and meta-analysis

BACKGROUND

Low back pain may be having a significant impact on emergency departments around the world. Research suggests low back pain is one of the leading causes of emergency department visits. However, in the peer-reviewed literature, there has been limited focus on the prevalence and management of back pain in the emergency department setting. The aim of the systematic review was to synthesize evidence about the prevalence of low back pain in emergency settings and explore the impact of study characteristics including type of emergency setting and how the study defined low back pain.

METHODS

Studies were identified from PubMed and EMBASE, grey literature search, and other sources. We selected studies that presented prevalence data for adults presenting to an emergency setting with low back pain. Critical appraisal was conducted using a modified tool developed to assess prevalence studies. Meta-analyses and a meta-regression explored the influence of study-level characteristics on prevalence.

RESULTS

We screened 1187 citations and included 21 studies, reported between 2000 and 2016 presenting prevalence data from 12 countries. The pooled prevalence estimate from studies of standard emergency settings was 4.39% (95% CI: 3.67-5.18). Prevalence estimates of the included studies ranged from 0.9% to 17.1% and varied with study definition of low back pain and the type of emergency setting. The overall quality of the evidence was judged to be moderate as there was limited generalizability and high heterogeneity in the results.

CONCLUSION

This is the first systematic review to examine the prevalence of low back pain in emergency settings. Our results indicate that low back pain is consistently a top presenting complaint and that the prevalence of low back pain varies with definition of low back pain and emergency setting. Clinicians and policy decisions makers should be aware of the potential impact of low back pain in their emergency settings.

Spondylitis transmitted from infected aortic grafts: a review

Graft infection following aortic aneurysms repair is an uncommon but devastating complication; its incidence ranges from <1% to 6% (mean 4%), with an associated perioperative and overall mortality of 12% and 17.5-20%, respectively. The most common causative organisms are Staphylococcus aureus and Escherichia coli; causative bacteria typically arise from the skin or gastrointestinal tract. The pathogenetic mechanisms of aortic graft infections are mainly breaks in sterile technique during its implantation, superinfection during bacteremia from a variety of sources, severe intraperitoneal or retroperitoneal inflammation, inoculation of bacteria during postoperative percutaneous interventions to manage various types of endoleaks, and external injury of the vascular graft. Mechanical forces in direct relation to the device were implicated in fistula formation in 35% of cases of graft infection. Partial rupture and graft migration leading to gradual erosion of the bowel wall and aortoenteric fistulas have been reported in 30.8% of cases.

Rarely, infection via continuous tissues may affect the spine, resulting in spondylitis. Even though graft explantation and surgical debridement is usually the preferred course of action, comorbidities and increased perioperative risk may preclude patients from surgery and endorse a conservative approach as the treatment of choice. In contrast, conservative treatment is the treatment of choice for spondylitis; surgery may be indicated in approximately 8.5% of patients with neural compression or excessive spinal infection. To enhance the literature, we searched the related literature for published studies on continuous spondylitis from infected endovascular grafts aiming to summarize the pathogenesis and diagnosis, and to discuss the treatment and outcome of the patients with these rare and complex infections.

Vomiting and Hyponatremia Are Risk Factors for Worse Clinical Outcomes Among Patients Hospitalized Due to Nonsurgical Abdominal Pain: A Retrospective Cohort Study

After initial evaluation in the Emergency Department (ED), many patients complaining of abdominal pain are classified as suffering from nonsurgical abdominal pain (NSAP). Clinical characteristics and risk factors for worse prognosis were not published elsewhere.Characterizing the clinical profile of patients hospitalized due to NSAP and identifying predictor variables for worse clinical outcomes.We made a retrospective cohort analysis of patients hospitalized due to NSAP compared to matched control patients (for age, gender, and Charlson comorbidity index) hospitalized due to other, nonsurgical reasons in a ratio of 1 to 10. We further performed in-group analysis of patients admitted due to NSAP in order to appreciate variables (clinical and laboratory parameters) potentially associated with worse clinical outcomes.Overall 23,584 patients were included, of which 2144 were admitted due to NSAP and 21,440 were matched controls. Patients admitted due to NSAP had overall better clinical outcomes: they had lower rates of in-hospital and 30-days mortality (2.8% vs 5.5% and 7.9% vs 10.4% respectively, P < 0.001 for both comparisons). They also had a significantly shorter length of hospital stay (3.9 vs 6.2 days, P < 0.001). Rates of re-hospitalization within 30-days were not significantly different between study groups. Among patients hospitalized due to NSAP, we found that vomiting or hyponatremia at presentation or during hospital stay were associated with worse clinical outcomes.Compared to patients hospitalized due to other, nonsurgical reasons, the overall prognosis of patients admitted due to NSAP is favorable. The combination of NSAP with vomiting and hyponatremia is associated with worse clinical outcomes.

Spinal epidural abscess

Spinal epidural abscess (SEA) remains a relatively infrequent diagnosis. Staphylococcus aureus is the most common organism identified, and the infectious source in SEA emanates from skin and soft tissue infections in about 20 % of instances. The thoracic spine is most often involved followed by the lumbar spine. The classic triad of fever, spinal pain, and neurological deficit is present in but a minority of patients. The appearance of neurological deficits with SEA has a significant impact on the prognosis; therefore, early diagnosis is imperative. Magnetic resonance imaging has permitted earlier diagnosis, although significant delays in diagnosis are common due to the nonspecific symptoms that frequently attend the disorder. Due to the rarity of this condition, there have been few randomized controlled trials to evaluate new treatment strategies, and most recommendations regarding treatment are based on case series studies often derived from the experiences at a single center.