Taking an accurate history to diagnose Cauda Equina Syndrome (CES)

Classic teaching is to inquire specifically about bowel and bladder function, sexual dysfunction, and/or loss of sensation in the groin.

Rather than asking about urinary incontinence, clinicians should ask specifically about difficulty passing urine, new leakage and retention.

Discussing issues related to sexual dysfunction are difficult for both clinicians and patients.

Rather than asking if there are any issues with sexual function, a more direct and informative way would be to ask if the patient has a “change in ability to achieve an erection or ejaculate” or “loss of sensation in genitals during sexual intercourse.”

Saddle anesthesia has the highest predictive value in diagnosing MRI-proven CES. Loss of sensation may be incomplete and patchy. Ask about change in sensation with wiping after a bowel movement.

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Timeliness of Concussion Referral

Do patients with a self-limited diagnosis of “concussion” require specialty follow up?

If so, is there a benefit to earlier evaluation?

Recently published research from the University of Pittsburgh Sports Medicine Concussion Program suggests so.

Subjects: 162 concussed athletes between the ages of 12 and 22

Findings: Athletes treated in the first week after injury recovered faster than those who did not receive care until 8 to 21 days post injury.

Note: Once in care the length of time spent recovering was the same for both groups. This suggests that the amount of time prior to the initiation of care may explain the longer recovery time of the 2^nd group.

Earlier recovery can help minimize effects on mood, quality of life and lost time in school/work.

Take home:  Consiuder early follow up referral to a qualified provider for all concussed patients seen in the ED

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Known effects and side effects of prescribed medicines may masquerade as cauda equina syndrome (CES) .

Analgesic medicines used by patients with chronic back pain may also cloud the diagnosis of CES.

Cholinergic medications (glaucoma/myasthenia) may lead to voiding issues.

Anticholinergic medications (COPD/urinary incontinence) may lead to urinary retention.

Opioids – Constipation, reduced bladder sensation

Anticonvulsants (Gabapentin/Pregabalin)- Urinary incontinence

Antidepressants (Amitriptyline) – Urinary retention, sexual dysfunction, reduced awareness of need to pass urine

NSAIDs – Urinary retention.

• 2.3 fold greater risk versus non users.  Higher in those aged 45 years or older, Highest risk (3.3 fold) was observed in patients who had recently started using NSAIDs. Dose dependent association.  

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Slipped Capital Femoral Epiphysis (SCFE)

• Progressive, posterior medial displacement (slipping) of the proximal femoral epiphysis
  • Complicated by AVN and premature physis closure

http://www.raymondliumd.com/images/SCFE%20illustrated%20and%20cropped.jpg

Early Diagnosis:

• Allows best chance for intervention and good functional outcome

• Subtle and difficult with X-ray

• Classic teaching is Klein’s line

Klein’s Line on AP view

• A line drawn from the superior aspect of the femoral neck will not intersect the femoral head epiphysis

• Modified line
  • >2mm difference in width lateral to line between each side

https://pedemmorsels.com/wp-content/uploads/2018/01/Slipped-Capital-Femoral-Epiphysis-3.png

Another virtual line may assist in diagnosis

S-sign

• The S-sign is a curvilinear line drawn on the inferior margin of the proximal femoral head neck junction along the proximal femoral physis.
•  Discontinuity or an abrupt sharp turn are abnormal

https://images.squarespace-cdn.com/content/v1/562149a6e4b0bca6fa53cb35/1530197888065-AOF0LA079Y81Q6M89RJU/ke17ZwdGBToddI8pDm48kE2XMWnCJSZ3ROkmIxQ7DdsUqsxRUqqbr1mOJYKfIPR7LoDQ9mXPOjoJoqy81S2I8N_N4V1vUb5AoIIIbLZhVYxCRW4BPu10St3TBAUQYVKcIZH9X6Fb-UKi0lvZd9RVmtFt1P_lj4JzgsdTxe78uiejbzfgXQaCWxJNArJhpf7P/Screen+Shot+2018-06-26+at+10.09.17+AM.png?format=1500w

Klein's line and S-sign

• A group of 20 orthopedic surgeons, radiologists, and pediatricians viewed 35 radiographs of SCFE using Klein's line on the AP view and the S-sign on frog-leg lateral view to make the diagnosis. 

• Overall diagnostic accuracy was better with the S-sign than Klein's line, 92% vs 79%.
  • Sensitivity of the S-sign was 89%, specificity 95%. 
  • Sensitivity of Klein's line was 68%, specificity 89%. 

• Combined S-sign + Klein's line sensitivity was 96%, specificity 85%.

Consider adding both of these virtual lines/signs to your review of the pediatric hip plain film

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The role of skeletal muscle relaxants in the management of lower back pain in the ED

Patients with lower back pain (LBP) presenting to the ED are often treated with NSAIDs plus skeletal muscle relaxants.

A recent study in Annals of Emergency Medicine compared functional outcomes and pain in ED patients with acute non radicular LBP with 4 different treatment regimens.

1. Ibuprofen plus placebo
2. Ibuprofen plus baclofen
3. Ibuprofen plus metaxalone
4. Ibuprofen plus tizanidine

Conclusion: Adding a muscle relaxant to ibuprofen did not improve pain or improve function at 1 week following an ED visit for LBP.

Note: Prior studies have found no benefit to adding opioids or diazepam to NSAIDs  for ED patients with acute non radicular LBP

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Lateral hip pain is a common presentation of hip pain.

Typically seen in runners and women over the age of 40 who start unaccustomed exercise.

Pain from OA of the hip which is typically medial (groin pain)

Lateral hip pain has traditionally been diagnosed at trochanteric bursitis.

Research suggests that lateral hip pain may be multifactorial and better termed Greater trochanteric pain syndrome.

Pain from the gluteal medius and/or minimus due to non-inflammatory tendonopathy is likely causative. This may cause a secondary bursitis.

Pain is insidious, gradual worsens and is variable based on activity type.

Also, can be seen after a fall resulting in tearing.

Pain is described as a deep ache or bruise. It can stay localized or radiate down lateral thigh towards knee.

Patients report night/early morning pain and when rolling over onto the outer hip on affected side.

Fatigue from prolonged sitting, walking and single leg loading activities such as walking up stairs.

Provoking activities and postures cause compressive forces on the involved tendons.

            These generally occur when the hip is adducted across midline such as with

Side sleeping,

            Place pillow between legs to align pelvis and keep knee and hip in line

Crossed leg sitting

            Sit w/ knees at hip distance and feet on floor

Selfie poses - Standing w a hitched hip (pushing hip to the side).

Attempt to correct biomechanical issues before progressing directly to bursal steroid injection

            May only be a temporary fix if underlying issue not addressed.

A helpful clinical guide

https://bjgp.org/content/bjgp/67/663/479/F1.large.jpg?download=true

A recent epidemiology study in Pediatrics looked at concussions in 20 high school sports during the 2013–2014 to 2017–2018 school years.

For every athlete, one practice or competition was counted as one exposure.

Overall, 9542 concussions were reported for an overall rate of 4.17 per 10 000 athletic exposures (AEs).

Football continues to have the highest incidence with a concussion rate of 10.40 per 10 000 AEs.

As in previous studies, rates in competition (33.19 to 39.07 per 10 000 AEs) are increasing and higher than rates in practice which are lower and decreasing over the study period (5.47 to 4.44 per 10 000 AEs).

            This may reflect better reporting or increasing injury rate

In all 20 sports, recurrent concussion rates decreased from 0.47 to 0.28 per 10 000 AEs.

Confirming prior studies, among sex-comparable sports, concussion rates were higher in girls than in boys (3.35 vs 1.51 per 10 000 AEs).

Also, among sex-comparable sports, girls had larger proportions of concussions that were recurrent than boys (9.3% vs 6.4%).

This study may reflect effective implementation of strategies to reduce concussion incidence such as mandatory removal from play and more stringent requirements associated with return to play.

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Synthetic turf playing surfaces have been growing in popularity over the last decade and seem to have become a new standard.

Due to the need for durable fields that can accommodate multiple teams/activities, in addition to the high cost of maintaining grass and the need to conserve water, many parks and schools have switched from grass to turf. Turf is advertised as maintenance free but ….this is not the case.

Locally, at M&T Bank Stadium, groundskeepers drive a LitterKat turf sweeper across the field for 4 hours 2-3 times a week to ensure that the synthetic rubber is cleaned and distributed evenly. The field is also repainted every 4 games because the paint may become hard. The cost of this level of maintenance is beyond what many parks and local high schools can afford.

A recent study examined high school concussion data at almost 2000 high schools with over 14,000 recorded concussions. Researchers concluded that more concussions occurred in games than practices. Interestingly, they also found that playing surface was significantly associated with concussion. Almost 90% of all injuries occurred on turf-based surfaces. Turf outweighed all other mechanisms of injury, including helmet-to-helmet hits and grass playing surface. Between 10 and 15.5% of concussions occur from helmet to ground contact. In the NFL, this mechanism accounts for about 1 in 7 concussions.

Attempting to limit total exposure time in practice and games on turf surfaces may be beneficial until more study is needed.

Intersection Syndrome

De Quervain’s is a common tenosynovitis is involving the  the 1^st dorsal compartment of the wrist/forearm.

Intersection syndrome is a tenosynovitis that occurs at the intersection of the 1^st and 2^nd dorsal compartments.

Pathology located at crossing point of the 1^st compartment structures (APL and EBP) with the radial wrist extensors (ECRB and ECRL)

Occurs most commonly from repetitive wrist extension and is common in rowers, weight lifters, and in those playing racquet sports.

Occurs about 4 to 6cm proximal to the radiocarpal joint VERSUS De Quervain’s which occurs near the level of the radial styloid.

Pain worse with resisted wrist and thumb extension

Radiographs not required

Splint and start NSAIDs

Recalcitrant cases can be referred for corticosteroid injection

https://stemcelldoc.files.wordpress.com/2012/09/intersection-syndrome-referral-pain-pattern1.jpg

Imaging of Lisfranc Injuries

Tarsometatarsal fracture-dislocation

Anatomy

         3 Columns of the midfoot, divided by the tarsometatarsal joints

1. Medial
   1. First TMT joint
2. Middle
   1. 2^nd and 3^rd TMT joints
3. Lateral
   1. 4^th and 5^th TMT joints

The Lisfranc ligament

     - Extends from the 2^nd MT to the medial cuneiform

     - Critical to structure and stabilization of the 2^nd MT and the midfoot arch

Imaging 

Plain films: AP/lateral/oblique

Consider weight bearing view with contralateral comparison if high suspicion

CT: Can be useful to confirm abnormal plain films

MRI: not done in ED but can be used to diagnose pure ligament injuries

Below is a review of the lines of the foot which will ensure not missing this diagnosis. May be helpful to review with sample imaging.

Plain films findings: https://prod-images.static.radiopaedia.org/images/49189279/86408d5bae08ab80ae9ef377337ab7_big_gallery.jpeg

On AP view:

1. Discontinuity of a line drawn from the medial part of 2^nd MT to the medial side of the 2^nd cuneiform
2. Widening of the interval between the 1^st and 2^nd ray
3. Bony fragment in 1^st MT space (fleck sign) – Lisfranc ligament avulsion

On Lateral view:

1. Dorsal displacement of the proximal 1^st or 2^nd MT (may be subtle)

On the Oblique view:

1. Discontinuity of a line drawn from the medial border of the 3^rd cuneiform with the medial border of the 3^rd MT
2. Discontinuity of a line drawn from the medial side of the 4th MT with the medial side of the cuboid 

Remember that the lateral margin of the 5^th MT can project lateral to the cuboid (up to 3 mm)

Lines drawn on 2 view foot for review

https://radiopaedia.org/cases/lisfranc-ligament-normal-alignment

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Tarsometatarsal fracture-dislocation

The Lisfranc ligament is critical for stabilization of the midfoot arch and the 2^nd MT

Injuries can range from mild (sprains) to severe (gross dislocation)

Injury may be purely ligamentous injuries or a fracture-dislocations

Difficult diagnosis to make

https://www.aafp.org/afp/1998/0701/afp19980701p118-f4.jpg

Mechanisms: MVAs, fall from height or athletic injuries

            Common athletic mechanism: Axial load to a hyperplantar flexed forefoot

https://thumbs.dreamstime.com/z/vector-illustration-healthy-human-foot-foot-lisfranc-injury-weight-bearing-mechanism-injury-100392176.jpg

Injury severity is often underestimated

Severe pain and inability to weight bear

Plantar bruising and bruising throughout midfoot

https://footeducation.com/wp-content/uploads/2019/02/Figure-3-Bruising-from-Lisfranc-Injury-600x781.png

No specific tests as exam is limited due to pain

Midfoot stress tests

-Often positive but unlikely to be allowed by patient due to pain

https://www.youtube.com/watch?v=v8SGVwz2RHs

Midfoot instability test

Grasp metatarsal heads and apply dorsal force to forefoot.

Other hand palpates the TMT joints and feels for dorsal subluxation

Plica Syndrome

-A painful impairment of knee function resulting from thickened and inflamed synovial folds

Plicae are embryologic remnant inward folds of the synovial lining present in most knees

Most plica are asymptomatic

A pathological synovial plica can become inelastic, thickened and fibrotic. It may bowstring across the femoral trochlea at 70 to 100 degrees of knee flexion

Can be a cause of anterior knee pain/mechanical Sxs

Medial patellar plica most commonly involved

Hx: Snapping sensation, pain w/ sitting or repetitive activity

Anterior knee pain, clicking, clunking, and a popping sensation on knee loading activity such as squatting/stairs or with prolonged sitting

Many present with history of blunt trauma to the anterior knee

PE: A taut band of tissue that reproduces concordant pain with palpation

Tenderness in the medial parapatellar region

Painful, palpable medial parapatellar cord

-This can be rolled and popped beneath the examiners finger

The knee may be tender to the touch, swollen, and stiff 

Can be difficult to distinguish from other intra-articular conditions such as meniscal tears, articular cartilage injuries, or osteochondral lesions,

The examiner can then palpate for the plica by rolling one finger over the plica fold, which is located around the joint lines in anterior knee compartment

https://www.ortho.com.sg/wp-content/uploads/2018/04/medial-plica-syndrome-31-e1478966479644.jpg

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Bone stress injury (BSI) in Adolescents

A BSI occurs along a pathology continuum that begins with a stress reaction and may progress all the way to a stress fracture.

Difficult to diagnose clinically.

Identifying risk factors as part of the history is very important.

Common sites for BSI are most frequently in the lower extremity and include the tibia, fibula, tarsals and metatarsals, calcaneus, and femur.

When considering this in an ED setting, image the involved area and if there is no fracture, advise discontinuing the activity until time of PCP/sports medicine follow up. For those with rest pain, pain with minimal weight bearing or in whom a fracture was suspected but not present, consider providing a walking boot or crutches.

BSIs occur more frequently in young athletes than in adults.         

          Almost 50% of BSIs occur in those younger than 20 years of age

Primary care and sports medicine providers are seeing more of these patients due to many factors.

Year-round training, sports specialization at younger ages and increase in training intensity/duration contribute to the increase incidence in adolescents.

Not surprisingly, participation in organized sports as an adolescent is a known risk factor.

Just as a change in sporting level from high school to college is a known risk factor for BSI, young “gifted” athletes who are promoted to competing with the varsity team may be at similar risk.

Shin pain lasting more than 4 weeks may represent a unique subset of MSK pain complaints increasing risk of BSI.

A prior history of BSI is a strong predictor of future BSI.

Inquire about night pain, pain with ambulation, and pain affecting performance.

Athletes with BSIs have a significantly lower BMI than controls (<21.0 kg/m2).

Athletes with BSIs sleep significantly less than controls.

Athletes with BSIs have significantly lower dairy intake than controls.

Inquire about components of the female athlete triad (low energy availability, menstrual dysfunction and low bone mineral density)

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Long head of biceps tendon (LHBT) Testing

Overhead activities can cause anterior shoulder pain due to LHBT instability. A review of 3 physical exam maneuvers for bedside evaluation.

Speed test

Shoulder at 90° of flexion with arm fully supinated and elbow extended

Patient attempts to fwd. elevate arm against a downward force

Positive test is pain localized to bicipital groove.

Sensitivity 54% and specificity 81% for biceps pathology

https://youtu.be/N00gA4Pvsbw

Yergason test

Elbow at 90° of flexion with arm fully pronated and held against thoracic wall. Examiner grips patient’s hand and resists attempts at supination.

Positive test is pain localized to bicipital groove or LHBT subluxation.

Sensitivity 41% and specificity 79% for biceps pathology

https://youtu.be/_ot2S75mZ3o

Upper Cut test

Shoulder neutral with Elbow at 90° of flexion, arm fully supinated and hand in a fist. Patient moves hand toward chin in an uppercut motion like a boxer. Examiner places hand over patient’s fist and resists upward movement.

Positive test is pain localized to bicipital groove or LHBT subluxation.

Sensitivity 73%, specificity 78%, +LR 3.38 for biceps pathology

https://youtu.be/EE-WhlWFZvk

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Children are prone to inflammation and infection of the intervertebral discs

-Mean age 3-5years at presentation.

Lumbar region frequently involved

Although disc biopsy is not necessary for diagnosis, as many as 60% of biopsied discs grow bacteria

-Usually Staphylococcus aureus.

Untreated - may spontaneously resolve or progress to vertebral osteomyelitis or abscess

Chief complaint: Back pain and irritability, often associated with a limp or refusal to crawl or walk.

Fever is absent or low grade. 

Physical examination findings are nonspecific and may include a tendency to lie still and percussion tenderness over the involved spine.

Blood culture is generally sterile,

WBC count can be normal early in the disease course

However, the ESR is elevated in >90% of patients.

Plain radiographs are normal at the start of the illness, and generally take 2-3 weeks to demonstrate narrowing of the intervertebral space.

Therefore imaging study of choice is MRI.

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Acute transverse myelitis (ATM) refers to inflammation of gray and white matter in one or more adjacent spinal cord segments leading to acute/subacute dysfunction of all cord functions (i.e., motor, sensory, and autonomic).

There is a bimodal peak between ages 10-19 years and ages 30-39 years.

Most cases are idiopathic

Some patients may have had a preceding viral infection or autoimmune disorder.

The thoracic cord is most commonly involved.

Onset is characterized by acute/subacute development of neurologic signs and symptoms consistent with motor weakness, sensory changes or autonomic dysfunction.

Pain in the head, neck, and/or back may occur.

Motor and sensory changes occur below the level of the lesion and are more likely to be bilateral.

Motor symptoms include a rapidly progressing paraparesis.

Autonomic dysfunction may include urinary urgency or difficulty voiding, bowel or bladder incontinence, tenesmus, constipation, and sexual dysfunction.

Despite its low incidence, consider in a patient presents with a classic constellation of symptoms,

Rapid identification, and early initiation of treatment predicts the best outcomes

Diagnosis: whole spine MRI with and without gadolinium

Management: goals include reducing cord inflammation (IV glucocorticoids), alleviating symptoms (pain management, bladder decompression), and treating underlying causes (e.g., infections, autoimmune) as appropriate.

Bone tumors can present as MSK pain!

Pain may be activity related initially (can lead to misdiagnosis)

Over time will progress to rest pain and night pain

1) Primary osteosarcoma - most common primary malignant bone tumor

Adolescents, male > female

70% occur about the knee (also in hip/pelvis and upper arm)

pain, swelling, tenderness to palpation

Consider in the presentation of non traumatic knee pain!

2) Ewing's sarcoma

Peak incidence ages 10-20, male > female

pain, swelling, tendernes to palpation

Elevated temps and ESR

Consider in the differential of osteomyelitis!!

Variable location - lusually the extremities but also pelvis, scapula, ribs

The TACO method (tarp assisted cooling with oscillation)

Cold water immersion (CWI) remains the standard for cooling in exercise induced hyperthermia

A low cost alternative is modified cold water immersion.

Sometimes, monetary reasons and location venue prevent the feasibility of CWI

Benefits: fast, cheap, portable

Portable – Allows for on site location at area of collapse

Cheap: Equipment required – 3 providers, 1 tarp, 20 gallons of water and 10 gallons of ice

Fast: Average time to set up – 3.4 minutes

The TACO method – fast effective reduction in core temperatures

              May be up to 75% as effective as CWI

https://www.youtube.com/watch?v=RxjP0-_RIdc

Show References

• A recent retrospective study examined CT radiation doses in different types of facilities

• Mean patient age: 12 years
• Authors reviewed radiation doses for nearly 240,000 CT scans in over 500 facilities
•  
• The facilities were categorized into 4 groups: 

• 1) academic pediatric,
• 2) non-academic pediatric,
• 3) academic adult, 
• 4) non-academic adult

Most (65%) scans were performed at nonacademic adult centers

• Radiation doses were significantly higher at adult facilities vs. pediatric facilities
• Also, radiation doses were higher at non-academic vs. academic facilities
• For example, the largest children received twice the radiation dose for abdomen-pelvis CT scans performed at nonacademic adult facilities compared with academic pediatric facilities
  • 11.9 mGy vs. 5.8 mGy
• Academic pediatric facilities use lower radiation doses than do nonacademic pediatric or adult facilities for all head CT examinations and for the majority of chest and abdomen-pelvis

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Laboratory testing for Spinal Epidural Abscess

CBC

The CBC is poorly sensitive/specific

The WBC count may be nml or elevated

Left shift and bandemia may or may not be present

ESR and CRP

Sensitive but not specific

Elevated in >80% with vertebral osteomyelitis.

• Sensitive for spinal infection, but not extremely specific.

• ESR
  • ESR was elevated in 94-100% of patients with SEA vs. only 33% of non-SEA patients
• CRP
  • Less useful for acute diagnosis since CRP levels rise faster and return to baseline faster than ESR
    • Elevated CRP seen in 87% of patients with SEA as well as in 50% of patients with spine pain not due to a SEA
  • Better used as a marker of response to treatment.

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