Case Presentation
Dave Choi
PGY-4
Emergency Medicine
Edmonton
Learning Goals
 Present an interesting case
 Briefly review relevant material
 Be done in 25 minutes… really.
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”
History
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
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
History
 Noticed lower back pain at night
initially
 No history of trauma
 Constant pain
 Mildly relieved by hot compresses,
and pain medications
 Activity doesn’t make it better or
worse
 Wakes him up at night sometimes
History
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

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
History
 No fever, chills, night sweats
 ~5lb weight loss over last
couple months
Red Flags
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Pain not relieved by lying down
Night pain
Leg weakness
Bowel, bladder, sexual symptoms
Fever (esp. IVDU)
Weight loss
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.
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?
O/E
 Vitals: T36.8, P54, RR15, BP137/83,
Sat 99%
 Heart S1S2, no EHS/murmurs/rubs
 Lungs clear, AE=AE
 Abd soft, normal BS, bit tender
suprapubic, no peritoneal
signs/guarding
 No pulsating mass, no flank
tenderness
MSK Exam
 No erythema/warmth/swelling over
back
 Pain is midline but not worse with
palpation
 No atrophy legs
 Normal SLR tests (Lasegue’s)
 Normal ROM lower back (Schober’s)
 Normal gait
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
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
Differential Dx Low
Back Pain
 Mechanical (>95%)
-
Lumbar strain (70%), degenerative process (10%), herniated disk
(4%), spinal stenosis (3%), OP compression # (4%),
spondylolisthesis (2%), traumatic # (<1%), congenital disease
(<1%), disc disruption
 Non-mechanical spinal conditions
(~1%)
-
Neoplasia, infection, inflammatory arthritis, Paget’s
 Visceral disease (~2%)
-
Disease of pelvic organs, renal disease, AAA, GI
PLAN
 D/C home?
 Any other
investigations?
- FAST (aorta)
 Follow up?
10 days later…
 Patient sent into ER from GP’s
office for in/out cath and
urinalysis
 Lower abdominal discomfort
 Cannot sleep
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
10 days later…
 Urinalysis: 3+ leuks, many
bacteria
 Started on Septra
 Discharged home with U/S
pelvis booked for next day
PLAN
 Leave catheter in
 Toradol 30mg IM
 Buscopan 10mg PO
Patient feels bit
better
• U/S pelvis
tomorrow
It’s 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
Case continued
 Urology
consult for
cystoscopy as
outpatient
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
28 days later
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-
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
Case continued
 Working Dx = Urinary retention
2o to BPH and LBP (mechanical)
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
Investigations
 Pt booked for outpt MRI L-spine
for ?neurogenic claudication by
GP
 Cystoscopy – mildly enlarged
prostate
2 weeks later…
 Returns to ED c/o gradual
bilateral leg weakness L>R
 Has been unable to walk
independently over last 4 days
(using walker)
 Foley catheter in situ x 3 weeks
 Unable to cope at home
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
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 Hoffman’s,
no Babinski, normal
bulbocavernosus reflex and rectal
tone
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 (<0.45) Glu2.6 (2.2-4.4) neg
cultures
 Diagnosis?
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
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
 Male:Female 4:1
 Usually >50yo
 Symptoms gradual onset over
months to years
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
Investigation /
Treatment
INVESTIGATION
 MRI
 Myelogram
 angiography
TREATMENT
 Embolization of AVM
 Laminectomy w/ obliteration of AV
shunt
Case
 Electrodiagnostic Study
- Axonal injury to leg muscles L>R
- Considerable # motor neurons
still intact, prognosis for
functional recovery reasonably
good
Mr. G now
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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
Summary
 Red flags for Low back pain
 Multiple ER visits with same
problem, do not get blinded by
the “diagnosis”