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Medical Legal 101 with Greg Henry - Focus on Back Pain, Pt 1

Mike Weinstock, MD and Greg Henry, MD
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We see so many patients with back pain that it is easy to let our guard down. We need to maintain a high index of suspicion for epidural compression syndrome, abdominal aortic aneurysm, and cancer. The test of choice should be very sensitive to exclude the diagnosis.

 

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Angelina M. -

I had a female pt in her 20s today with a hx of ehlers danlos syndrome come in complaining of severe low back pain. She states she gets severe pain in SI joints about 3 times per yr from SI joint dysfunction and normally PT and muscle relaxants help. However, most of her pain was mid-line lower lumber and esp sacral and when asked about high risk features she noted new onset urinary retention the past few days which she had never had before when she has had the pain. No UTI sxs. Her pain was radiating into b/l thighs with some weakness and shaking in left leg with exam which was also new. Her DTRs were decreased but she noted that was her baseline. She noted gradual increase in difficulty in ambulating, that she thought was not just due to pain; her gait was however normal. To me, this seemed concerning for cauda equina; however, when I tried talking to my supervising physician and other colleagues they made it sound like it was okay to have her get close f/u with her PCP for an MRI same day or next day and that if I send her to the ED they will most likely send her home without an MRI. This was news to me! So my question is, how time sensitive is this exactly (if you can arrange outpt f/u does it need to be same day, within hrs, etc) and does the recommendation to emergently transfer to the ED change if they have different red flag symptoms? Thanks so much

Mike W., MD -

Hi Angelina, thx for the question. I am writing back with some urgency as this patient needs to go immediately to the ED and after 23 years experience in the ED, we would 100% do an emergent MRI. The urinary retention is SUPER concerning, esp with the leg Sx and the his of Ehlers Danlos syndrome. Please inform me of the outcome and good luck!!

Angelina M. -

I did not end up seeing your reply until I was done with my shift but I do really replace you getting back to me. BUT, I DID end up sending her to the ED despite what I was being told bc I was not comfortable having her wait for f/u after listening to all the UC RAP lectures and medical legal cases. Im not sure of her course in the ED other than I did check our imaging system and they did end up doing an MRI which showed a "large left subarticular disc protrusion at L5-S1 partially
compressing the traversing left subarticular S1 nerve root and displacing the left descending S2 nerve root. Moderate spinal stenosis due to disc protrusion." So... no cauda equina syndrome, but still Im happy I sent her and glad you agree it was the right choice. I was just very surprised today that people were recognizing that yes cauda equina syndrome is an emergent condition but then somehow the workup could take place in the next 1-2 days which made me think there was somthing I was missing/ not understanding or if the emergent part of it did not come on until a patient had full blown sxs and exam consistent with cauda equina. Thanks again!

Mike W., MD -

Thx for the follow up Angelina - you did the right thing. Take care!

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The Barky Cough Conundrum Full episode audio for MD edition 179:45 min - 84 MB - M4Ahippo Urgent Care RAP - February 2017 Summary 277 KB - PDF