Case Presentation

1
Case Presentation

• Dave Choi
• PGY-4
• Emergency Medicine
• Edmonton

2
Learning Goals

• Present an interesting case
• Briefly review relevant material
• Be done in 25 minutes really.

3
The Case

• Day shift at the Foothills
• Just finished resusitating a level 1 trauma
  patient
• Feeling good about your intubation and chest tube
  skills, you move to the minor side to see a
  patient with low back pain

4
History

• Mr G. 58 y.o. male
• Walked into ER
• c/o lower back pain x 1/12
• Seen by GP last week given toradol and percocet,
  also put on Flomax for BPH

5
History

• Noticed lower back pain at night initially
• No history of trauma
• Constant pain
• Mildly relieved by hot compresses, and pain
  medications
• Activity doesnt make it better or worse
• Wakes him up at night sometimes

6
History

• Pain has been getting bit worse
• Worse with coughing, straining
• Radiating to flank/groin x 1/52
• Some voiding difficulty (hard start) x 1/52
• No bowel incontinence

7
History

• No fever, chills, night sweats
• 5lb weight loss over last couple months

8
Red Flags

• Pain not relieved by lying down
• Night pain
• Leg weakness
• Bowel, bladder, sexual symptoms
• Fever (esp. IVDU)
• Weight loss

9
History

• PmHx ? cholesterol
• Meds Crestor 10mg PO QD, Percocet 1tab PO Q4H
  prn, Toradol 10mg PO Q6H prn
• Allergies NKDA
• FHx father MI at 80 y.o.

10
History

• SHx
• non smoker
• occas. EtOH
• no illegal drugs
• worked as senior manager for Telus, retired
  earlier this year, exercises 3x/week, going on
  holidays soon
• ANY OTHER QUESTIONS?
• Ddx?

11
O/E

• Vitals T36.8, P54, RR15, BP137/83,
• Sat 99
• Heart S1S2, no EHS/murmurs/rubs
• Lungs clear, AEAE
• Abd soft, normal BS, bit tender suprapubic, no
  peritoneal signs/guarding
• No pulsating mass, no flank tenderness

12
MSK Exam

• No erythema/warmth/swelling over back
• Pain is midline but not worse with palpation
• No atrophy legs
• Normal SLR tests (Lasegues)
• Normal ROM lower back (Schobers)
• Normal gait

13
Neuro Exam

• Motor 5/5 power UE, Slight decreased power L hip
  flexor, otherwise normal
• Sensation normal UE/LE, no saddle anesthesia,
  normal rectal tone, mild prostate enlargement
• DTR 2 bilat UE, 1 bilat LE, no Babinski

14
Investigations

• Xray Lspine - mild degen changes
• Hgb158 WBC5.9 Plt 243
• Na140 K4.1 Cl105 bicarb27
• Cr100, Urea5.5
• Urine neg leuks/protein/hgb
• Bladder scanned for 154ml

15
Differential Dx Low Back Pain

• Mechanical (gt95)
• Lumbar strain (70), degenerative process (10),
  herniated disk (4), spinal stenosis (3), OP
  compression (4), spondylolisthesis (2),
  traumatic (lt1), congenital disease (lt1), disc
  disruption
• Non-mechanical spinal conditions (1)
• Neoplasia, infection, inflammatory arthritis,
  Pagets
• Visceral disease (2)
• Disease of pelvic organs, renal disease, AAA, GI

16
PLAN

• D/C home?
• Any other investigations?
• FAST (aorta)
• Follow up?

17
10 days later

• Patient sent into ER from GPs office for in/out
  cath and urinalysis
• Lower abdominal discomfort
• Cannot sleep

18
Physical Exam

• Chest clear
• Abd bit distended, dull to percussion,
  suprapubic discomfort to palpation, symmetric
  fullness
• Neuro exam unchanged from previous
• Bladder scanned for 550ml, foley drained 500ml,
  foley left in

19
10 days later

• Urinalysis 3 leuks, many bacteria
• Started on Septra
• Discharged home with U/S pelvis booked for next
  day

20
PLAN

• Leave catheter in
• Toradol 30mg IM
• Buscopan 10mg PO
• Patient feels bit better
• U/S pelvis tomorrow

21
Its tomorrow

• U/S abdo/pelvis normal GB bile ducts, liver
  grossly normal, pancreas, spleen, aorta normal,
  multiple bilateral renal cysts, but kidneys
  otherwise normal
• Now what?
• Dx prostate hyperplasia, UTI, and mechanical
  back pain

22
Case continued

• Urology consult for cystoscopy as outpatient

23
28 days later

• Still c/o back pain worse at night
• Very tender suprapubic area
• Numbness / tingling feet started 1 week ago
• Meds Flomax, Proscar, Flexeril, Percocet prn,
  Toradol prn

24
28 days later

• O/E AVSS
• Neuro Exam
• Motor 4/5 hip flexors, others 5/5
• Sensation numb over plantar feet bilat,
  touch/pinprick ok
• DTR 1 LE bilat, 2 UE bilat, no Babinski
• No saddle anesthesia
• Rectal tone intact

25
Case continued

• Working Dx Urinary retention 2o to BPH and LBP
  (mechanical)

26
Hmm

• Pt returns to ED 3 more times in the next 4 days
  c/o urinary retention and suprapubic discomfort
• Now c/o bilateral numbness/tingling feet and
  lower back pain radiating to bilateral thighs

27
Investigations

• Pt booked for outpt MRI L-spine for ?neurogenic
  claudication by GP
• Cystoscopy mildly enlarged prostate

28
2 weeks later

• Returns to ED c/o gradual bilateral leg weakness
  LgtR
• Has been unable to walk independently over last 4
  days (using walker)
• Foley catheter in situ x 3 weeks
• Unable to cope at home

29
Recap of the Events

• LBP, gradual onset and worsening, night pain,
  worse with valsalva x 4/12
• Pain radiating to bilat thighs and groin x 3/12
• Numbness/tingling bilat feet, ascending from feet
  to thigh x 1/12
• Urinary retention x 1/12, indwelling foley x 3/52
• Gradual bilateral leg weakness x 2/52

30
Neuro Exam Now

• Motor UE normal 3/5 Hip flexors, 3/5 Quads,
  4/5 Hamstrings, 4/5 ankle dorsi/plantarflexion
• Sensation saddle anesthesia!
• Reflexes no DTRs LE, no Hoffmans, no Babinski,
  normal bulbocavernosus reflex and rectal tone

31
Case continued

• Admitted under neurosurgery
• MRI syrinx vs inflammatory or neoplastic cord
  disease, suggest LP by neurology to r/o viral
  etiology
• Lumbar Puncture WBC103 RBC96 Prot4.15 (lt0.45)
  Glu2.6 (2.2-4.4) neg cultures
• Diagnosis?

32
Case

• CT chest/abd no aortic dissection
• MRA suspicious for dural AV fistula arising
  from upper lumbar region causing ischemia
• OR L2-4 laminectomy and clipping of spinal
  dural AV fistula

33
Dural AV fistula

• a.k.a. Foix-Alajouanine Syndrome
• AV malformation of spinal cord vessels, usually
  lower thoracic or lumbosacral
• Can lead to ischemic injury of the cord
• MaleFemale 41
• Usually gt50yo
• Symptoms gradual onset over months to years

34
Symptoms / Signs

• Weakness / numbness / tingling of LE
• Gradual onset worsening LE weakness
• Urinary / fecal incontinence
• lower back pain /- radiating
• Abnormal gait
• Spastic or flaccid paraparesis /- sensory level
• DTR variable /- Babinski
• Decreased rectal tone

35
Investigation / Treatment

• INVESTIGATION
• MRI
• Myelogram
• angiography
• TREATMENT
• Embolization of AVM
• Laminectomy w/ obliteration of AV shunt

36
Case

• Electrodiagnostic Study
• Axonal injury to leg muscles LgtR
• Considerable motor neurons still intact,
  prognosis for functional recovery reasonably good

37
Mr. G now

• Back pain significantly reduced
• Unable to ambulate
• Self in/out catheterizations
• BMs ok
• Still hoping to go on planned holidays to Hawaii
  in the future

38
?
39
Summary

• Red flags for Low back pain
• Multiple ER visits with same problem, do not get
  blinded by the diagnosis