Retroperitoneal Organs

• Adrenals
• Aorta 
• IVC
• Duodenum
• Pancreas
• Ureters
• Colon (Ascending and Descending) k
• Kidneys
• Esophagus
• Rectum

Physical Exam Findings

• Won't show up acutely
• Grey  Turner's
• Cullen's
• Stabler's sign
• Fox's sign
  

Symptoms

     1. Most common presenting complaint = abdominal pain; then leg/hip pain; back pain

     2. Can have femoral neuropathy, iliopsoas spasm


Traumatic RPH

• Majority are blunt injuries 
  

Spontaneous RPH

• Elderly, anticoagulated pts - significant mortality
• 33% of people with spontaneous RPH are not anticoagulation 
• Consider in people with vague hip / leg pain

Management
- controversial

      Zone I - concern for vascular injury - likely OR

      Zone II & III - ?pulsatile, ?expanding - determines intervention

      Packing vs arterial embolization - majority of traumatic RPH are venous in nature


CORE CONCEPTS:

-  RPH is a rare diagnosis with significant mortality - see keep on your differential!
- Undress your adult patients too - look for Fox's sign, etc
- Most common presenting symptom: abdominal pain, then leg or back pain 
- Seen more commonly in elderly and those on anticoagulation, but 1/3 of pts who presented with spontaneous RPH were not on anticoagulation

Basics

• ~3% of all primary care visits are for lower back pain, the vast majority of which is mechanical or non-specific in origin. 
  
• >90% of low back pain has spontaneous resolution within two weeks regardless of treatment modality. 
  
• Less than 5% have serious pathology.

EM Perspective

• Time-sensitive emergencies = epidural abscess, cauda equina syndrome and vertebral osteomyelitis.

Red Flags
-Trauma
-Unexplained fever
-Immunosuppression/DM/steroid use
-IVDU
-Age >70
-Focal neurologic deficit
-History of spinal instrumentation
-Duration longer than 6 weeks

• Limit imaging to patients with the ‘red flag’ symptoms, MRI is the test of choice.  If MRI is unable to be obtained, CT is the second choice.

• Greater than 90% of disk herniations occur at L4-5 and L5-S1.  Test these motor distributions by examining ankle and great toe dorsiflexion as well as ankle plantarflexion.  Sensory distributions run along the posterior and lateral aspects of the lower extremity.

• 2007 ACP/APS Joint Practice Guidelines recommend NSAIDs as the first line of therapy for acute lower back pain.  Studied regimens were Ibuprofen 400-600mg QID or Naproxen 220-500 mg BID for 2-4 weeks.  Other studies have shown that NSAIDs combined with Skeletal Muscle Relaxants were the most effective regimen with symptom relief at one week.

• The classic triad of back pain, fever, and neurologic deficits only occurs in 13% of spinal epidural abscesses.

• The most common symptom of cauda equina syndrome is urinary RETENTION.  If this pathology is suspected, provide the patient with 10mg Decadron IV prior to MRI scan to prevent progression.

• All pediatric low back pain is ‘red flag’ back pain.  Up to 31% of these patients have a specific diagnosis such as tumors, discitis or malignancy.