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9 results

  • Chapter 8 - Musculoskeletal and Neurogenic Pain

  • from Section 2 - Common Neurologic Presentations: A Symptom-Based Approach
  • Edited by Thomas P. Campbell, Allegheny Health Network, Pittsburgh, Kevin M. Kelly, Allegheny Health Network, Pittsburgh
  • Book:
    Handbook of Emergency Neurology
    Published online:
    10 January 2024
    Print publication:
    17 August 2023, pp 94-107

  • Summary

    Pain is one of the most common presenting complaints in the emergency department (ED), both acute pain and exacerbation of chronic pain syndromes. Acute pain is accompanied by anxiety and sympathetic hyperactivity, whereas chronic pain is often associated with affective symptoms of depression. Nociceptive (musculoskeletal, inflammatory, or somatic) pain involves activation of the peripheral receptors secondary to tissue damage from trauma or heat. Neuropathic pain involves direct activation of either sensory nerves or ganglia by nerve injury or disease. Differentiation between nociceptive and neuropathic pain in the ED can be difficult, but should be considered for successful management of the pain.

  • Chapter 17 - Traumatic and Nontraumatic Spinal Cord Disorders

  • from Section 3 - Specific Neurological Disorders in Emergency Medicine
  • Edited by Thomas P. Campbell, Allegheny Health Network, Pittsburgh, Kevin M. Kelly, Allegheny Health Network, Pittsburgh
  • Book:
    Handbook of Emergency Neurology
    Published online:
    10 January 2024
    Print publication:
    17 August 2023, pp 246-268

  • Summary

    Traumatic spinal cord injury requires urgent imaging and decision-making involving a team approach. Causes of nontraumatic spinal cord injury are protean and can be roughly divided into compressive and non-compressive disease states. In general, it is the scenario of compressive spinal injury that needs to be identified quickly for possible urgent surgical decompression, whereas non-compressive injury requires a systematic work-up, which is somewhat less urgent. MRI is the imaging modality of choice for essentially all acute spinal cord disorders presenting to the ED, and the physician is charged with expeditious performance of this testing whenever spinal cord compression is deemed a likely possibility.

  • Just the facts: Risk stratifying nontraumatic back pain for Cauda Equina Syndrome in the emergency department

  • Zoe Polsky, Margriet Greidanus, Anjali Pandya, W. Bradley Jacobs
  • Journal:
    Canadian Journal of Emergency Medicine / Volume 22 / Issue 5 / September 2020
    Published online by Cambridge University Press:
    10 June 2020, pp. 652-654
    Print publication:
    September 2020
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  • A 43-year-old male, with a history of chronic back pain, presents to the emergency department (ED) with acute onset chronic pain. He states he “tweaked something” and has been debilitated by back pain, radiating down both his legs, for 24 hours. He has not had a bowel movement but denies noticing any “saddle anesthesia.” His clinical exam is limited by pain, and it is difficult to determine if he has objective weakness. His perineal sensation is intact, as is his sensation upon digital rectal examination. The patient has a post-void residual of 250 mL, but you are unsure how to interpret this value. As an emergency physician, when should you suspect, and how should you evaluate cauda equina syndrome?

  • Development of a toolkit for early identification of cauda equina syndrome

  • Sue Greenhalgh, Carole Truman, Valerie Webster, James Selfe
  • Journal:
    Primary Health Care Research & Development / Volume 17 / Issue 6 / November 2016
    Published online by Cambridge University Press:
    21 April 2016, pp. 559-567
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  • Aim

    To develop a simple cauda equina syndrome (CES) toolkit to facilitate the subjective examination of low back pain patients potentially at risk of CES. To undertake preliminary validation of the content of the toolkit.

    Background

    CES is a rare condition which can be very challenging to identify in a generalist medical setting.

    Method

    A three phase iterative design with two stake holder groups; extended scope practitioners experienced in managing CES patients and CES sufferers.

    Toolkit development

    Synthesis of existing CES literature with CES patient data generated from in depth interviews.

    Toolkit validation

    Content validation of the draft toolkit with CES patients.

    Toolkit validation

    Content validation of the draft toolkit with extended scope physiotherapists.

    Findings

    A three arm toolkit has been developed for use with patients considered by the clinician as at risk of developing CES (eg, worsening low back pain with symptoms/signs of progressive sensory-motor deficit in the lower limbs); patient expertise, clinical expertise, research and pathways. Uniquely, the toolkit drew upon the lived experiences of patients suffering from CES to inform the content.

  • Chapter 20 - Opioids

  • from Section 6 - The Management of Neuropathic Pain
  • Edited by Cory Toth, Dwight E. Moulin
  • Book:
    Neuropathic Pain
    Published online:
    05 December 2013
    Print publication:
    07 November 2013, pp 240-248

  • Summary

    Nerve root compression can occur from osteophyte formation, disc herniation, or a combination. As only 1-2% of patients with back pain have a nerve root or spinal cord compression, an accurate diagnosis of the causes of painful radiculopathy relies on a thorough history and physical exam. It is important to note that many asymptomatic individuals have abnormalities such as disc herniations and foraminal stenosis on CT and MRI. Therefore, the imaging findings must be correlated with the history and examination findings. Surgery for spinal stenosis and neurogenic claudication is indicated if severe pain is present, and can provide sustained relief. Since the spinal cord terminates at the L1-2 vertebral level, lumbar pathology below this level may compress the distal nerve root, causing a cauda equina syndrome. A lesion affecting the lumbosacral plexus (LSP) can present with pain in the low back, hip or pelvis, or with sciatica pain.

  • 31 - Chronic obstructive pulmonary disease

  • from Section 5 - Respiratory emergencies
  • Edited by Kaushal Shah, Jarone Lee, Kamal Medlej, American University of Beirut, Scott D. Weingart
  • Book:
    Practical Emergency Resuscitation and Critical Care
    Published online:
    05 November 2013
    Print publication:
    24 October 2013, pp 208-212

  • Summary

    This chapter discusses the diagnosis, evaluation and management of acute spinal cord compression. It presents special circumstances which make diagnosis and management of Cauda equina syndrome difficult. Spinal shock is characterized by a loss of spinal cord function below the level of the lesion. Cervical and thoracic level lesions may be associated with respiratory compromise. The spinal shock results in a disruption of sympathetic innervation causing unopposed parasympathetic tone, which may also cause hypotension and bradyarrhythmias (neurogenic shock). The spinal shock is characterized by flaccid paralysis and loss of bladder/bowel control. The diagnosis of acute spinal cord compression is suggested by history and physical examination, and confirmed by radiography or surgical intervention. Clinical presentations may vary depending on the level of neurological injury. The most likely causes for sudden decompensation in spinal cord include expansion of the ending lesion causing worsening neurological compromise or a high cervical/thoracic lesion.

  • Chapter 17 - Structural issues forneurohospitalists

  • Edited by S. Andrew Josephson, University of California, San Francisco, W. David Freeman, David J. Likosky
  • Book:
    Neurohospitalist Medicine
    Published online:
    07 October 2011
    Print publication:
    29 September 2011, pp 213-223

  • Summary

    Acute and subacute spinal cord disorders are an important area of hospital medicine given the high risk of devastating neurological complications. This chapter presents the clinical characteristics, diagnosis, differential diagnosis, treatment and prognosis of the following spinal disorders: spinal epidural abscess, transverse myelitis, cauda equina syndrome, spinal cord injury, vascular myelopathies, and neoplastic disorders. Spinal cord trauma can be acutely life-threatening or result in severe chronic disability. Appropriate initial management is crucial to maximizing eventual neurological function. Like cerebral stroke, vascular myelopathy is considered when myelopathic deficits develop abruptly. Spinal epidural abscess results from hematogenous seeding of infection either directly into the epidural space, or to the vertebral body or intervertebral disk with subsequent spread into the epidural space. Cauda equina syndrome (CES) is most commonly due to anatomical compression from a large central disc. Metastases are the most common type of tumor affecting the spine.

  • Delayed presentation of cauda equina syndrome secondary to lumbar disc herniation: functional outcomes and health-related quality of life

  • Jason W. Busse, Mohit Bhandari, Joseph B. Schnittker, Kesava Reddy, R. Brett Dunlop
  • Journal:
    Canadian Journal of Emergency Medicine / Volume 3 / Issue 4 / October 2001
    Published online by Cambridge University Press:
    21 May 2015, pp. 285-291
    Print publication:
    October 2001
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  • Objective:

    Cauda equina syndrome (CES) is a feared complication of lumbar disc herniation. It is generally accepted that CES requires decompression within 6 hours of symptom onset, but this time goal is rarely met, and the relative benefit of delayed decompression on functional status and quality of life (QOL) remains unknown. The study objective was to describe the functional status and quality of life outcomes for patients who undergo delayed surgical decompression for CES.

    Methods:

    Patients with CES who underwent decompression of a herniated lumbar disc during a 10-year period were assessed at hospital discharge and at least 4 months after the procedure. Evaluation of functional outcomes was based on a previously validated scale and QOL outcomes on the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) questionnaire.

    Results:

    During the study period, 1100 patients with herniated discs were identified, and 14 underwent surgical decompression for CES. All 14 had had symptoms for more than 38 hours before surgery. Ten patients were available for long-term follow-up. There was a strong correlation between long CES symptom duration and poor functional outcome: of 8 patients with symptoms for less than 10 days before decompression (range, 1.6–7.5 d), all had good functional outcomes. The 2 patients with more prolonged symptoms (10.6 and 14.2 d) had poor outcomes. SF-36 scores demonstrated declines in physical roles (p = 0.03), social function (p = 0.03) and increased pain (p = 0.003) compared with population norms. Correlation between SF-36 domain scores and CES symptom duration failed to achieve statistical significance, perhaps because of small sample size.

    Conclusions:

    Patients who undergo delayed decompression for CES have increased pain and impaired social and physical function. Longer delays correlate with worse functional outcomes. Beyond 24 hours, decompression delay may be associated with a poorer quality of life but, because of the rarity of CES, the sample size in this study was too small to provide definitive conclusions. Since no patients underwent surgery within 38.4 hours of symptoms, it is not possible to comment on the importance of emergent decompression in early presenters.