Thoraco-Lumbar X-ray Interpretation

  1. Check it’s an adequate view
  2. Know your anatomy
  3. Check the alignment
  4. Look for loss of vertebral height
  5. Look for widened inter-spinous or inter-pedicle distance and check the processes
  6. Check for translation/rotation or distraction
  7. Know the common types of fractures

TUNA FISH

Avoid lumbar spine imaging in the emergency department for adults with non-traumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition (RED FLAGS) (such as vertebral infection, cauda equina syndrome, or cancer with bony metastasis).

 

Lower Back Pain

Lumbosacral sprain is a diagnosis of exlusion:

  • Lumbosacral sprain or mechanical back pain is a diagnosis of exclusion, made only after carefully ruling out serious causes of low back pain.

Management of lumbosacral sprain:

  1. Education This is a mechanical problem requiring a mechanical solution – and pain medications alone will not fix the problem. Patients need to play an active role in their recovery, and prolonged bed rest will worsen the problem.
  2. Reassurance 90% get better with time (over weeks)
  3. Symptom Management Evidence from the Cochrane collaboration supports heat, NSAIDs, acetaminophen, massage and physical therapy. Muscle relaxants may be as effective as NSAIDs, but they have significant side effects, especially in combination with opioids.

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Back Pain in the ED

 

Most patients with atraumatic back pain don’t require lumbar spine x-rays. They carry a high radiation exposure and are of limited diagnostic utility except in the very elderly patients when osteoporotic fractures or metastatic disease might be apparent.

Choosing wisely: Unnecessary tests and treatments cost money and harm your patient financially (DO NO HARM)!

  1. Don’t order CT head scans in adults and children who have suffered minor head injuries (unless positive for a head injury clinical decision rule).
  2. Don’t prescribe antibiotics in adults with bronchitis/asthma and children with bronchiolitis.
  3. Don’t order lumbosacral (low back) spinal imaging in patients with non-traumatic low back pain who have no red flags/pathologic indicators
  4. Don’t order neck radiographs in patients who have a negative examination using the Canadian C-spine rules.
  5. Don’t prescribe antibiotics after incision and drainage of uncomplicated skin abscesses unless extensive cellulitis exists.

EM Don’ts

  1. Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma and a normal neurological evaluation.
  2. Avoid CT pulmonary angiography in emergency department patients with a low-pretest probability of pulmonary embolism and either a negative Pulmonary Embolism Rule-Out Criteria (PERC) or a negative D-dimer.
  3. Avoid lumbar spine imaging in the emergency department for adults with atraumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition, such as vertebral infection or cancer with bony metastasis.
  4. Avoid prescribing antibiotics in the emergency department for uncomplicated sinusitis.
  5. Avoid ordering CT of the abdomen and pelvis in young otherwise health emergency department patients with known histories of ureterolithiasis presenting with symptoms consistent with uncomplicated kidney stones.