Avoidable Imaging Wave II

Avoidable Imaging Wave II
Low Back Pain (Clinical Topic)

Presenter Jonathan Edlow, MD

Acute Atraumatic Back Pain
Avoiding Unnecessary Imaging Jonathan A. Edlow, MD FACEP Department of Emergency Medicine Beth Israel Deaconess Medical Center Professor of Emergency Medicine Harvard Medical School Boston, MA

Objectives Learn to use an ED clinical guideline for evaluation of patients presenting with acute non-traumatic back pain in order to reduce the misdiagnosis Use history and physical examination to identify RED FLAGS that suggest the possibility of spinal cord or cauda equina compression Develop strategies to reduce unnecessary imaging

Algorithm for Management of Non-traumatic Back Pain ^
(based on expert consensus and national non-emergency medicine-based guidelines) Caution: consider non-spine causes of back pain (not covered in this algorithm) LOW RISK No Red Flags* & normal neurological exam (or isolated root finding c/w sciatica) INTERMEDIATE RISK Presence of ≥ 1 history Red Flags* AND normal neurological exam (or isolated single root finding c/w sciatica) HIGH RISK Any new abnormality on neurological exam (except for isolated single root finding c/w sciatica) No routine lab testing, imaging, or consults Treat symptoms Use NSAID; opioids for severe pain Consider a muscle relaxant 2-3 days of bedrest for severe pain Rapid return to normal activities Explain the problem & treatment to the patient PCP follow-up Written instructions about symptoms for which to return (development of red flags) Options based on clinical judgement: Further risk stratification CRP or ESR if ? cancer or spinal abscess Consultation (neurology or spine surgery) Timing of imaging Emergent MRI in the ED Urgent in next 48 hours Disposition Discharge with urgent MRI & PCP follow-up Admission to hospital for observation EMERGENCY MRI facilitate rapid imaging of the correct portion of spine (see text for MRI checklist) Consider (case-by-case): Empiric antitiotics Empric IV dexamethasone Relavant consutations Caution: Communicate clearly with the patient The plan, the concerns & the follow-up Symptoms for which to return to the ED Coordinate with PCP or admitting physician Treat symptoms with analgesics Negative MRI Review with radiologist Is the scan truly negative? Is the scan technically adequate? Have the correct levels been imaged? Repeat the neurological exam Is it truly abnormal? Has it evolved? Consider lumbar puncture Admission for further evaluation Positive MRI Consult spine surgeon for definitive care Start ED-based treatments and/or consults based on the diagnosis * Red Flags (for cord/cauda equina compression) History Epidural abscess: fever, immunocompromised, IVDA, h/o bacteremia Epidural tumor: history of systemic cancer or weight loss Epidural hematoma: anticoagulation or recent spinal anesthesia General: new frequent falls or ataxia, ≥3 weeks of midline pain, nocturnal pain, sphincter incontinence or urinary urgency, bilateral leg symptoms Physical examination Motor - weakness in legs (or arms) Sensory - sensory level or saddle anesthesia Reflexes - diminished or abnormal reflexes including positive Babinski sign Sphincter dysfunction - lax rectal tone (rectal optional but perform in intermediate or high risk patients) or post-void residual > 100 cc’s ^ Solid lines indicate usual care; dotted lines indicate options based on case-by-case clinical judgment.

(based on expert consensus and national non-emergency medicine-based guidelines) Caution: consider non-spine causes of back pain (not covered in this algorithm) Posterior penetrating ulcer Retroperitoneal hematoma Acute pyelonephritis Acute cholangitis AAA Aortic dissection Acute pancreatitis

Central disc herniation Tumor
Anterior Central disc herniation Tumor Epidural abscess Epidural hematoma Posterior

Who needs an MRI? When do they need it? How should the MRI be protocoled?

(based on expert consensus and national non-emergency medicine-based guidelines) Caution: consider non-spine causes of back pain (not covered in this algorithm) LOW RISK No Red Flags* & normal neurological exam (or isolated root finding c/w sciatica) INTERMEDIATE RISK Presence of ≥ 1 history Red Flags* AND normal neurological exam (or isolated single root finding c/w sciatica) HIGH RISK Any new abnormality on neurological exam (except for isolated single root finding c/w sciatica) No routine lab testing, imaging, or consults Treat symptoms Use NSAID; opioids for severe pain Consider a muscle relaxant 2-3 days of bedrest for severe pain Rapid return to normal activities Explain the problem & treatment to the patient PCP follow-up Written instructions about symptoms for which to return (development of red flags) Options based on clinical judgement: Further risk stratification CRP or ESR if ? cancer or spinal abscess Consultation (neurology or spine surgery) Timing of imaging Emergent MRI in the ED Urgent in next 48 hours Disposition Discharge with urgent MRI & PCP follow-up Admission to hospital for observation EMERGENCY MRI facilitate rapid imaging of the correct portion of spine (see text for MRI checklist) Consider (case-by-case): Empiric antitiotics Empric IV dexamethasone Relavant consutations Caution: Communicate clearly with the patient The plan, the concerns & the follow-up Symptoms for which to return to the ED Coordinate with PCP or admitting physician Treat symptoms with analgesics Negative MRI Review with radiologist Is the scan truly negative? Is the scan technically adequate? Have the correct levels been imaged? Repeat the neurological exam Is it truly abnormal? Has it evolved? Consider lumbar puncture Admission for further evaluation Positive MRI Consult spine surgeon for definitive care Start ED-based treatments and/or consults based on the diagnosis * Red Flags (for cord/cauda equina compression) History Epidural abscess: fever, immunocompromised, IVDA, h/o bacteremia Epidural tumor: history of systemic cancer or weight loss Epidural hematoma: anticoagulation or recent spinal anesthesia General: new frequent falls or ataxia, ≥3 weeks of midline pain, nocturnal pain, sphincter incontinence or urinary urgency, bilateral leg symptoms Physical examination Motor - weakness in legs (or arms) Sensory - sensory level or saddle anesthesia Reflexes - diminished or abnormal reflexes including positive Babinski sign Sphincter dysfunction - lax rectal tone (rectal optional but perform in intermediate or high risk patients) or post-void residual > 100 cc’s ^ Solid lines indicate usual care; dotted lines indicate options based on case-by-case clinical judgment.

(based on expert consensus and national non-emergency medicine-based guidelines) Caution: consider non-spine causes of back pain (not covered in this algorithm) LOW RISK No Red Flags* & normal neurological exam (or isolated root finding c/w sciatica) INTERMEDIATE RISK Presence of ≥ 1 history Red Flags* AND normal neurological exam (or isolated single root finding c/w sciatica) HIGH RISK Any new abnormality on neurological exam (except for isolated single root finding c/w sciatica) * Red Flags (for cord/cauda equina compression) History Epidural abscess: fever, immunocompromised, IVDA, h/o bacteremia Epidural tumor: history of systemic cancer or weight loss Epidural hematoma: anticoagulation or recent spinal anesthesia General: new frequent falls or ataxia, ≥3 weeks of midline pain, nocturnal pain, sphincter incontinence or urinary urgency, bilateral leg symptoms Physical examination Motor - weakness in legs (or arms) Sensory - sensory level or saddle anesthesia Reflexes - diminished or abnormal reflexes including positive Babinski sign Sphincter dysfunction - lax rectal tone (rectal optional but perform in intermediate or high risk patients) or post-void residual > 100 cc’s

RED FLAGS What is the evidence base behind the red flags? Overall the evidence is quite weak Best validated - History of cancer, corticosteriod use (fracture) & anticoagulant use New physical findings including new ataxia & difficulty walking History findings suggest risk (of neurological problem) Hard physical findings suggest presence (of neurological problem) Groups of red flags may perform better than single ones and one must factor in the context

RED FLAGS Epidural tumor - h/o systemic cancer, weight loss
History - specific diagnoses Epidural tumor - h/o systemic cancer, weight loss Epidural abscess - fever, immunocompromised state, IVDA, h/o recent bacteremia/UTI Epidural hematoma - anticoagulation, recent spinal anesthesia

RED FLAGS Bilateral leg symptoms
History - general factors New frequent falls and/or difficulty walking Duration ≥3 weeks of midline back pain Pain wakes patient from sleep Sphincter incontinence and urinary urgency Lhermitte’s sign (electric shock-like sensation shooting down spine & limbs on neck flexion) Bilateral leg symptoms Bilateral leg symptoms

RED FLAGS Weakness or sensory level
Physical Examination Weakness or sensory level New ataxia (even without demonstrable motor or sensory signs) Diminished or abnormal reflexes Full bladder (consider checking for PVR>100cc by bladder scan or US) Saddle anesthesia or lax rectal tone Test saddle anesthesia in all patients In intermediate or high-risk patients, do rectal exam & PVR

RED FLAGS Is there a history of? On physical exam, is there:
Fever ______ IVDA ______ Recent bacteremia ______ Immunocompromised state(s) ______ Systemic cancer ______ Recent unintentional weight loss ______ Anticoagulant use ______ Recent spinal surgery or spinal anesthesia ______ New frequent falls or inability to walk ______ > 3 weeks of midline pain or pain worse at night ______ Feeling of abnormal urination or defecation ______ Numbness in legs or saddle area ______ Weakness in arms or legs ______ Lhermitte’s sign ^ _____ Bilateral leg weakness or numbness ______ On physical exam, is there: Fever ______ Full or insensate bladder * ______ Weakness in arms or legs ______ Unexplained new inability to walk ______ Sensory level (including saddle anesthesia) ______ Abnormal reflexes # ______ Diminished or absent rectal sphincter tone ______ ^ - Electric shock-like sensation shooting down spine/limbs on neck flexion * - Check by PVR or bladder scanner or US (> 100 cc is abnormal) # - diminished in LMN lesion; increased or + Babinsky in UMN lesion

Dangerous Diagnoses without Red Flags
Cauda equina Sphincter symptoms may not be present Saddle anesthesia may preceed lower leg/foot signs Cancer ~ 20% of cases, the vertebral metastasis is the presenting symptom Abscess ~ 66% have fever at presentation 10% present with the classic triad (fever, back pain & neurological deficit) Hematoma 30% have no identifiable reason for bleeding Patients with normal exams and no red flags will be very difficult to diagnose on first visit. This is one of the reasons for careful follow-up instructions to the patient. CAUTION: These patients are very difficult to diagnose at first visit; clear discharge instructions and follow-up care mitigate this issue

(based on expert consensus and national non-emergency medicine-based guidelines) Caution: consider non-spine causes of back pain (not covered in this algorithm) HIGH RISK Any new abnormality on neurological exam (except for isolated single root finding c/w sciatica) EMERGENCY MRI facilitate rapid imaging of the correct portion of spine (see text for MRI checklist) Consider (case-by-case): Empiric antitiotics Empric IV dexamethasone Relavant consutations Negative MRI Review with radiologist Is the scan truly negative? Is the scan technically adequate? Have the correct levels been imaged? Repeat the neurological exam Is it truly abnormal? Has it evolved? Consider lumbar puncture Admission for further evaluation Positive MRI Consult spine surgeon for definitive care Start ED-based treatments and/or consults based on the diagnosis * Red Flags (for cord/cauda equina compression) History Epidural abscess: fever, immunocompromised, IVDA, h/o bacteremia Epidural tumor: history of systemic cancer or weight loss Epidural hematoma: anticoagulation or recent spinal anesthesia General: new frequent falls or ataxia, ≥3 weeks of midline pain, nocturnal pain, sphincter incontinence or urinary urgency, bilateral leg symptoms Physical examination Motor - weakness in legs (or arms) Sensory - sensory level or saddle anesthesia Reflexes - diminished or abnormal reflexes including positive Babinski sign Sphincter dysfunction - lax rectal tone (rectal optional but perform in intermediate or high risk patients) or post-void residual > 100 cc’s ^ Solid lines indicate usual care; dotted lines indicate options based on case-by-case clinical judgment.

(based on expert consensus and national non-emergency medicine-based guidelines) Caution: consider non-spine causes of back pain (not covered in this algorithm) HIGH RISK Any new abnormality on neurological exam (except for isolated single root finding c/w sciatica) EMERGENCY MRI facilitate rapid imaging of the correct portion of spine (see text for MRI checklist) Consider (case-by-case): Empiric antitiotics Empric IV dexamethasone Relavant consutations Negative MRI Review with radiologist Is the scan truly negative? Is the scan technically adequate? Have the correct levels been imaged? Repeat the neurological exam Is it truly abnormal? Has it evolved? Consider lumbar puncture Admission for further evaluation Positive MRI Consult spine surgeon for definitive care Start ED-based treatments and/or consults based on the diagnosis ^ Solid lines indicate usual care; dotted lines indicate options based on case-by-case clinical judgment.

(based on expert consensus and national non-emergency medicine-based guidelines) Caution: consider non-spine causes of back pain (not covered in this algorithm) HIGH RISK Any new abnormality on neurological exam (except for isolated single root finding c/w sciatica) MRI Checklist Ensure that safety checklist has been filled out and sent to the appropriate place If there are absolute contraindications, do not send to MRI Discuss alternative options (CT or conventional myelogram) with the radiologist Ensure that pain and anxiety are controlled and that the patient can lie flat for the likely duration of the scan Consider procedural sedation if there are adequate medical staff to safely monitor patient, factoring in the logistics of proximity of MRI department to the ED Endotracheal intubation and sedation may be necessary; have SPINE see patient pre-intubation Decide what part of the spine needs imaging In patients with back pain and up-going toes, isolated LS-spine imaging is insufficient If spinal epidural abscess or metastatic cancer are important concerns, the entire spine should be imaged - but START with the likey area of the symptomatic lesion! With abscess, skip areas occur that may affect surgical planning With cancer, multiple metastases occur in 33% of patients that may affect radiation therapy planning Speak to the radiologist Dicsuss urgency of the case in order to prioritze based on other patients in the queue Ensure that the scan is properly protocolized for the specific diagnostic concern regarding use of contrast (which facilitates diagnosis of epidural abscess and metastases) EMERGENCY MRI facilitate rapid imaging of the correct portion of spine (see text for MRI checklist) ^ Solid lines indicate usual care; dotted lines indicate options based on case-by-case clinical judgment.

Cauda Equina Syndrome The spinal cord stops at ~ L1
Posterolateral HNP: sciatica The spinal cord stops at ~ L1 There is no spinal cord in the L-S spine, (only nerve roots floating in the CSF) Typical disc disease usually causes unilateral symptoms of a single root; with cauda equina, multiple roots are involved and symptoms are often bilateral Sphincter symptoms are common Bilateral sciatica is cauda equina till proven otherwise Central HNP: cauda equina ordering a LS-spine MR for r/o cord compression is like ordering a chest CTA to r/o appendicitis. UMN vs LMN lesion.

Spinal cord Cauda equina

Clinical Implications
Ordering a L-S spine MRI to “rule out ‘cord compression’ ” is like ordering a chest CTA to rule out appendicitis If you clinically exclude a ‘cord lesion’ because there are no leg findings (L4-S1) without checking sphincter symptoms & signs and saddle anesthesia (S2-4), you will miss some cauda equina patients ordering a LS-spine MR for r/o cord compression is like ordering a chest CTA to r/o appendicitis. UMN vs LMN lesion. A back pain patient with a + Babinski sign has an UMN lesion (cord or higher). In a back pain patient with a cauda equina lesion, a LMN lesion, the reflexes are decreased

(based on expert consensus and national non-emergency medicine-based guidelines) Caution: consider non-spine causes of back pain (not covered in this algorithm) LOW RISK No Red Flags* & normal neurological exam (or isolated root finding c/w sciatica) No routine lab testing, imaging, or consults Treat symptoms Use NSAID; opioids for severe pain Consider a muscle relaxant 2-3 days of bedrest for severe pain Rapid return to normal activities Explain the problem & treatment to the patient PCP follow-up Written instructions about symptoms for which to return (development of red flags) * Red Flags (for cord/cauda equina compression) History Epidural abscess: fever, immunocompromised, IVDA, h/o bacteremia Epidural tumor: history of systemic cancer or weight loss Epidural hematoma: anticoagulation or recent spinal anesthesia General: new frequent falls or ataxia, ≥3 weeks of midline pain, nocturnal pain, sphincter incontinence or urinary urgency, bilateral leg symptoms Physical examination Motor - weakness in legs (or arms) Sensory - sensory level or saddle anesthesia Reflexes - diminished or abnormal reflexes including positive Babinski sign Sphincter dysfunction - lax rectal tone (rectal optional but perform in intermediate or high risk patients) or post-void residual > 100 cc’s ^ Solid lines indicate usual care; dotted lines indicate options based on case-by-case clinical judgment.

What data support the “no imaging" recommendation?
Misconceptions about what patients want Background noise Randomized trial data “Side effects” of imaging

North Carolina Back Pain Project
Misconceptions: North Carolina Back Pain Project 208 random doctors selected (PCPs, HMO PCPs), orthopedists, chiropractors ~ 1600 consecutive patients with acute low back pain were enrolled 6 month outcomes (functional status, patient satisfaction) by phone at 6 months Direct health-care dollars spent Orthopedists/chiropractors >> PCPs >> HMO PCPs Amount of imaging performed Orthopedists/chiropractors >> PCPs >> HMO PCPs Outcomes ? Identical Carey; 1995; NEJM; 333:

What correlated with patient satisfaction?
Satisfaction was higher with chiropractors than with physicians But what specific elements of care were important? Perception that a detailed history was taken Perception that a complete physical exam was done Perception that the doctor clearly explained the cause of the problem What was not important? Imaging tests

Background noise: How often is the MRI “normal”?
MRIs in 100 asymptomatic patients (and 27 back pain patients) read by 2 neuroradiologists Of the asymptomatic patients, Only 36% were “normal” 52% had “disc bulges” (non-focal) 27% had a focal “disc protrusion” 1% had a frankly herniated disc Other findings (Schmorl’s nodes 19%, annular defects 14%, facet joint arthritis 8%) These numbers are average of the 2 radiologists Schmorl’s node - herniation of disc into the vertebral-body end plate Jensen; 1994; NEJM; 331: 69-73

Randomized trial: Does MRI improve patient outcomes?
380 primary care patients randomized to plain films vs rapid MRI (doctor had ordered a plain film) Clinical outcomes at 12 months were identical Cost were lower with plain films Primary care population. Doctor had to order a plain film to be enrolled. Jarvik; JAMA; 2003; 289:

Side effects: What happens after MRI?
ED length of stay for MRI/interpretation Consequences of the “positive” findings Consults Additional imaging to sort out ambiguity More steroid injections More spine surgery These numbers are average of the 2 radiologists Schmorl’s node - herniation of disc into the vertebral-body end plate

Side effects: What happens after MRI?
These numbers are average of the 2 radiologists Schmorl’s node - herniation of disc into the vertebral-body end plate Webster; Spine; 2014:

(based on expert consensus and national non-emergency medicine-based guidelines) Caution: consider non-spine causes of back pain (not covered in this algorithm) INTERMEDIATE RISK Presence of ≥ 1 history Red Flags* AND normal neurological exam (or isolated single root finding c/w sciatica) No routine lab testing, imaging, or consults Treat symptoms Use NSAID; opioids for severe pain Consider a muscle relaxant 2-3 days of bedrest for severe pain Rapid return to normal activities Explain the problem & treatment to the patient PCP follow-up Written instructions about symptoms for which to return (development of red flags) Options based on clinical judgement: Further risk stratification CRP or ESR if ? cancer or spinal abscess Consultation (neurology or spine surgery) Timing of imaging Emergent MRI in the ED Urgent in next 48 hours Disposition Discharge with urgent MRI & PCP follow-up Admission to hospital for observation EMERGENCY MRI facilitate rapid imaging of the correct portion of spine (see text for MRI checklist) Caution: Communicate clearly with the patient The plan, the concerns & the follow-up Symptoms for which to return to the ED Coordinate with PCP or admitting physician Treat symptoms with analgesics * Red Flags (for cord/cauda equina compression) History Epidural abscess: fever, immunocompromised, IVDA, h/o bacteremia Epidural tumor: history of systemic cancer or weight loss Epidural hematoma: anticoagulation or recent spinal anesthesia General: new frequent falls or ataxia, ≥3 weeks of midline pain, nocturnal pain, sphincter incontinence or urinary urgency, bilateral leg symptoms Physical examination Motor - weakness in legs (or arms) Sensory - sensory level or saddle anesthesia Reflexes - diminished or abnormal reflexes including positive Babinski sign Sphincter dysfunction - lax rectal tone (rectal optional but perform in intermediate or high risk patients) or post-void residual > 100 cc’s ^ Solid lines indicate usual care; dotted lines indicate options based on case-by-case clinical judgment.

(based on expert consensus and national non-emergency medicine-based guidelines) Caution: consider non-spine causes of back pain (not covered in this algorithm) INTERMEDIATE RISK Presence of ≥ 1 history Red Flags* AND normal neurological exam (or isolated single root finding c/w sciatica) No routine lab testing, imaging, or consults Treat symptoms Use NSAID; opioids for severe pain Consider a muscle relaxant 2-3 days of bedrest for severe pain Rapid return to normal activities Explain the problem & treatment to the patient PCP follow-up Written instructions about symptoms for which to return (development of red flags) * Red Flags (for cord/cauda equina compression) History Epidural abscess: fever, immunocompromised, IVDA, h/o bacteremia Epidural tumor: history of systemic cancer or weight loss Epidural hematoma: anticoagulation or recent spinal anesthesia General: new frequent falls or ataxia, ≥3 weeks of midline pain, nocturnal pain, sphincter incontinence or urinary urgency, bilateral leg symptoms Physical examination Motor - weakness in legs (or arms) Sensory - sensory level or saddle anesthesia Reflexes - diminished or abnormal reflexes including positive Babinski sign Sphincter dysfunction - lax rectal tone (rectal optional but perform in intermediate or high risk patients) or post-void residual > 100 cc’s ^ Solid lines indicate usual care; dotted lines indicate options based on case-by-case clinical judgment.

Patient who is HIV positive (RED FLAG) who is compliant on HAART therapy, had a non-detectable VL and a normal CD4 counts 3 months ago, who has lumbar back pain after exercise. The physical exam is normal. He is followed closely by a PCP. Otherwise healthy patient who has a few days of vague diffuse low back pain in the setting of a fever of 101 degrees (RED FLAG) associated with symptoms/signs of a specific localized infection. Patient who has low back pain who urinated while attempting to get to bathroom (RED FLAG) but on detailed history, the issue is that the pain slowed the person down getting to the bathroom and not that they truly lost control of urination - CHECK the PVR!! (or that a patient is constipated while taking narcotics but has good sphincter tone). Patient with low back pain on warfarin (RED FLAG) with a good story/exam for sciatica and an INR of 2.2.

(based on expert consensus and national non-emergency medicine-based guidelines) Caution: consider non-spine causes of back pain (not covered in this algorithm) INTERMEDIATE RISK Presence of ≥ 1 history Red Flags* AND normal neurological exam (or isolated single root finding c/w sciatica) EMERGENCY MRI facilitate rapid imaging of the correct portion of spine (see text for MRI checklist) * Red Flags (for cord/cauda equina compression) History Epidural abscess: fever, immunocompromised, IVDA, h/o bacteremia Epidural tumor: history of systemic cancer or weight loss Epidural hematoma: anticoagulation or recent spinal anesthesia General: new frequent falls or ataxia, ≥3 weeks of midline pain, nocturnal pain, sphincter incontinence or urinary urgency, bilateral leg symptoms Physical examination Motor - weakness in legs (or arms) Sensory - sensory level or saddle anesthesia Reflexes - diminished or abnormal reflexes including positive Babinski sign Sphincter dysfunction - lax rectal tone (rectal optional but perform in intermediate or high risk patients) or post-void residual > 100 cc’s ^ Solid lines indicate usual care; dotted lines indicate options based on case-by-case clinical judgment.

Neurological symptoms
Patient with an active history of IVDA who presents with 3 days of fever, increasingly severe, midline thoracic back pain and fever to 101 degrees (MULTIPLE RED FLAGS) and who also complains of decreased ability to urinate over the last 24 hours. The physical examination is normal. A ESR from the transferring hospital is 80. Neurological symptoms DANGELO,MARK SEA missed on first visit (“negative” wet read by rads resident) Very good discharge instructions; diagnosed with “prostatitis” based on tenderness on rectal exam.

(based on expert consensus and national non-emergency medicine-based guidelines) Caution: consider non-spine causes of back pain (not covered in this algorithm) INTERMEDIATE RISK Presence of ≥ 1 history Red Flags* AND normal neurological exam (or isolated single root finding c/w sciatica) Options based on clinical judgement: Further risk stratification CRP or ESR if ? cancer or spinal abscess Consultation (neurology or spine surgery) Timing of imaging Emergent MRI in the ED Urgent in next 48 hours Disposition Discharge with urgent MRI & PCP follow-up Admission to hospital for observation ^ Solid lines indicate usual care; dotted lines indicate options based on case-by-case clinical judgment.

Inflammatory Markers No systematic prospective studies in a group of “all-comers” of ED patients with back pain Most studies are of relatively small numbers of patients with a specific diagnosis (e.g., epidural abscess, tumor) For abscess and tumor, CRP & ESR are very sensitive (≥95%) Sensitivity for disc & hematoma not clear (but likely lower) Data are mixed about if CRP or ESR is better than the other The use of inflammatory markers are incorporated into most other guidelines

BEWARE the thoracic cord
Anterior The epidural space is smallest in the thoracic canal Metastatic tumor is more commonly located here (70% of MESCC is in T- spine) Disc disease is less common Therefore, bad diagnoses are more likely and there is less room for error in patients with thoracic lesions MESCC = metastatic epidural spinal cord compression Posterior

Evolution of Neurological Signs/Symptoms . . .
WHY ? Neurological symptoms especially with tumor and abscess Time . . . is unpredictable

Gradual onset cord compression from metastatic disease
Neurological symptoms this one is NOT collapsed (and not fractured), just bulging into canal Time

Sudden cord compression from pathologic fracture of L2
Neurological symptoms this one is fractured, T1 on left, STIR on R. Time

Algorithm for Management of Non-traumatic Back Pain
(based on expert consensus and national non-emergency medicine-based guidelines) LOW RISK No Red Flags* & normal neurological exam (or isolated root finding c/w sciatica) HIGH RISK Any new abnormality on neurological exam (except for isolated single root finding c/w sciatica) INTERMEDIATE RISK Presence of ≥ 1 history Red Flags* AND normal neurological exam (or isolated single root finding c/w sciatica) Vast majority of patients. No testing beyond careful clinical evaluation. Discharge with treatment, careful instructions to patients & family, and PCP follow-up. Relatively few patients. Here you need to use your judgment (bearing in mind the differential diagnosis & natural history) to decide on next steps, their timing and coordination. These are the rare patients with abnormal physical exams. Here you need to move really fast to get imaging, start treatments and coordinate with consultants to preserve function. Note that the yellow zone allows for dealing with these patients in a community hospital with medicine admit, consult and MRI in the AM if available (which it often is on a next day basis). LIMITATIONS: mostly primary care data, so there is almost certainly some severity bias, even of low-risk patients.

What's Next? Complete Sepsis Portal Activities
Questions? Contact the E-QUAL team at

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