What is the appropriate workup and management for a patient with a history of multiple sclerosis (MS) presenting to the emergency department with headache, back pain, and leg tingling?

Emergency Department Workup for Headache, Back Pain, and Leg Tingling in Multiple Sclerosis Patients

The emergency department workup for a patient with multiple sclerosis presenting with headache, back pain, and leg tingling should include urgent brain and spine MRI with contrast to rule out MS relapse, complications like cerebral venous thrombosis, and other neurological emergencies. 1, 2

Initial Assessment and Differential Diagnosis

Primary Considerations:

• MS relapse/exacerbation: New or worsening neurological symptoms lasting at least 24 hours 2
• Cerebral venous thrombosis: Can present with headache and neurological symptoms, especially in MS patients 2
• Intracranial hypotension: Can present with headache and neurological symptoms 2
• Spinal cord compression: Back pain with leg tingling/weakness

Secondary Considerations:

• Medication-related adverse effects
• Infection (especially in immunosuppressed patients)
• Other neurological conditions unrelated to MS

Diagnostic Workup Algorithm

1. Immediate Neurological Assessment

• Detailed neurological examination focusing on:
  • Mental status
  • Cranial nerve function
  • Motor strength
  • Sensory function
  • Deep tendon reflexes
  • Coordination
  • Gait (if possible)

2. Urgent Neuroimaging

• Brain MRI with and without contrast:

  • Assess for new or enlarging T2 lesions
  • Look for gadolinium-enhancing lesions indicating active inflammation 2
  • Evaluate for other pathologies (stroke, hemorrhage, venous thrombosis)

• Spine MRI with and without contrast:

  • Particularly important with back pain and leg tingling
  • Assess for new or enhancing lesions in the spinal cord
  • Rule out cord compression or other myelopathies 2, 1

3. Laboratory Testing

• Complete blood count
• Comprehensive metabolic panel
• Inflammatory markers (ESR, CRP)
• Consider lumbar puncture if:
  • Diagnosis is uncertain
  • Infection is suspected
  • Cerebral venous thrombosis is suspected 2

4. CSF Analysis (if LP performed)

• Cell count and differential
• Protein and glucose
• Cytology for malignant cells
• Oligoclonal bands
• PCR for viral infections if suspected 2

Management Based on Findings

If MS Relapse Confirmed:

• High-dose corticosteroids (methylprednisolone 1g IV daily for 3-5 days) 1
• Consider admission if:
  • Severe neurological deficits
  • Poor response to initial treatment
  • Inability to manage symptoms as outpatient

If Cerebral Venous Thrombosis Suspected:

• Urgent neurology consultation
• Consider anticoagulation (heparin) unless contraindicated
• Close neurological monitoring 2

If Intracranial Hypotension:

• Bed rest
• Hydration
• Consider epidural blood patch if severe 2

Special Considerations

Red Flags Requiring Immediate Attention:

• Altered mental status
• Seizures
• Severe headache of sudden onset
• Fever with neurological symptoms
• Progressive weakness or sensory changes

Medication-Related Considerations:

• Patients on immune checkpoint inhibitors may develop immune-related adverse events requiring specific management 2
• B-cell depleting therapies may reduce ED visits but increase infection risk 3

Follow-up Recommendations

• Neurology follow-up within 1-2 weeks
• Repeat MRI in 3-6 months to assess for new lesions and treatment response 2
• Consider adjustment of disease-modifying therapy if relapse is confirmed

Pitfalls to Avoid

1. Attributing all symptoms to MS without considering other causes: Always consider alternative diagnoses, especially with atypical presentations 4

2. Delaying MRI with contrast: Early imaging is crucial for diagnosis and treatment decisions 2

3. Missing cerebral venous thrombosis: This can be life-threatening and requires prompt diagnosis and treatment 2

4. Overlooking spinal cord pathology: Spine imaging is essential with back pain and leg symptoms 1

5. Failing to recognize medication-related adverse events: Particularly important in patients on newer MS therapies 2