back pain

[Eydawn]

Unfortunately, we didn't get to cover this specific problem in my neurobiology class. We did cover a lot, especially regarding what levels of the spinal cord will present with deficits/pain in which areas of the body... but I had never heard of Cauda Equina Syndrome until zzyyx posted it. And I didn't JFGI because that would have been cheating! Lol...

Ok, maybe I did hear it someplace before... but not enough about it to have it come to mind. The only thing I could think of was lower back pain due to a lift injury: compression of the cord from injury to the vertebra (osteoporosis, anyone) or a disk moving and putting pressure on the cord. Didn't think about it being low down enough to involve the cauda equina.

Wendy

CO EMT-B

[Dustdevil]

Hey, you got the problem, so that's good enough! Putting a syndrome name on it is just icing on the cake, if you can do it. And, of course, knowing that syndrome makes the root dx a little easier too.

As unknown to the average medic as Cauda Equina Syndrome is, this is definitely not a zebra. In fact, it's a lot more common than the AAA that we got sidetracked chasing. That's why this was such a good scenario. It was a great illustration of both distracting factors and overanalysing hoofbeats.

[ERDoc]

I respectfully have to disagree with you, Dust. AAA is much more common. Here are some stats from emedicine:

Frequency:

In the US: Ruptured AAA is the 13th-leading cause of death in the US, causing an estimated 15,000 deaths per year. The incidence of AAA is 2-4% in the adult population, and 11% of cases in that subset occur in males older than 65 years. Despite increased survival following diagnosis, incidence and crude mortality seem to be increasing.

Frequency:

In the US: CES is uncommon, both atraumatically as well as traumatically. It is often reported as a case report due to its rare presentation

I think AAA needs to be high on your differential in a case like this. I think this case also shows the value of a good history and physical. Lower back pain with numbness in the legs can occur from both AAA and CES. AAAs will not give you incontinence and usually will not cause motor function problems. A good history is the best medicine, the devil is in the details.

[Dustdevil]

Sorry, I should have been more specific. I wasn't really saying that CES specifically was that common. I was meaning caudal neuropathy secondary to lumbar injury is more common than an AAA, at least in my anecdotal experience. I've run countless lumbar injuries in the last thirty years, but I could count the triple As without running out of fingers. The scenario presented screamed spinal neuropathy, whether CES or otherwise. Of course, neither are zebras, and both are important differentials.

[NREMT-Basic]

I agree the BP, which could be that way everyday for the last month, isn't stable. Though I was called here for the back pain, my other findings are, in some respect, of more concern.

Be honest with him about the ER trip, whether it is with us or his daughter.

If the BP was 130/85, no, I probably would let him sign the refusal, tell him to call if he changes his mind and wish him well.

I'm guessing here but I might think about doing the Miami Stroke Test

Lets take a quick look at the definition of stable. Stable does not, in and of itself, mean good or bad. It means, to paraphrase Taber's, unchanging over a period or range of time. From what Ive read one BP was given. Another could not be had because he cant sit up (ruling out the ability to check for orthostatic changes). We cannot note a widening or narrowing BP with 1 set of vitals. He has never been to the Dr. before which likely means he has never ridden in an ambulance and you and your partner have your rig sitting in his front yard with your secondaries on. He heard the siren. Your cot is in the house. You are in the house. Perhaps medical types make him nervous.

Quite simply, his vital signs cannot be called stable or unstable because we have only one set. As I say, there is good stable and bad stable as in "stable and resting comfortably" or "stable but critical." Also he is in pain which we know drives up vitals and he is reporting a 10/10 on the UPS. I just recently had a doctor tell me that he doesnt freak over BP until he has 5 sets of vitals over 25 minutes and the BP is 230/130 and not going down. Not to long ago I assisted with a 17 year old girl having an anxiety attack because her boyfriend was dating someone else. Her BP was 220/150 because she had been sobbing for two straight hours before our arrival. 10 minutes on 12lpm via NRB and she was at 120/90, respirating a 14 per, pulse 86, PsO2 was 100% on NRB and 98 on room air. When the parents asked the my paramedic if she should be transported, he let her know that what she would get in ER would be more of what she was getting in the living room and though he certainly would not talk her out of going, she seemed to be in much better shape then when we arrived. Another 5 minutes on scene and our patient was talking to me about school and soccer, all vitals within parameter for a girl her age and after further discussion with the paremedic, the parents signed a refusal, we packed up and headed to dinner. Stable is objective and objectivity is not gained with one set of vital signs.