Back pain is a common ED presentation. Usually, the non-specific pain is mild to moderate and is aggravated by movement and relieved with rest. There are no risk factors for a serious disease on the history and physical examination.
Back Pain - Critical documentation components
ED Management
Pain lasting >6 weeks is an indicator of more serious disease, since most episodes of nonspecific back pain (80% to 90%) resolve within 6 weeks.
Red Flags
- Trauma (Fracture)
- Unexplained Weight Loss (Malignancy, Metastasis)
- Neurologic Symptoms (Coed COmpression)
- Age <18 years old and >50 years old (BOny abnormalities, Spinal Stenosis, AAA)
- Fever (Infection - Systemic, Osteomyelitis, Epidural Abscess)
- IVDU (Spinal Infection)
- Steroid Use, Immunocompromised (Infection)
- H/O Cancer (Metastasis)
Injection drug user + Back Pain = Spinal infection (Osteomyelitis, Epidural Abscess)
Elderly + Back Pain - Think Aortic Pathology
Bowel or bladder incontinence + Back Pain = Cauda equina syndrome
Back Pain - Critical documentation components
- Fever
- Localised warmth/tenderness
- Abdominal Masses
- Renal Angle Tenderness
- Sensory-Motor Exam (Perianal/Saddle Anesthesia)
- Reflexes
- Rectal Exam (Tone, Masses) - Must be performed in those with neurologic complaints or findings or other red flags for back pain
- SLRT (screening examination for a herniated disk) - With the patient lying supine, lift each leg separately to approximately 70 degrees in an attempt to produce radicular pain. A positive straight leg raise test causes a radicular pain radiating below the knee of the affected leg. This pain is worsened by ankle dorsiflexion and improved with ankle plantar flexion or decreasing leg elevation.
Ankle Plantarflexion – S1
ED Management
- FBC, ESR/CRP, Urine Analysis, ALP, Ca (Only if clinically indicated)
- LS Spine X-Ray (with h/o trauma)
- For most patients, no testing is required
- MRI/CT Myelogram in suspected Epidural Abscess
Patients who resume their normal activities to the furthest extent tolerable recover more rapidly than those bed rest. Management options include:
Take Home
- Analgesics (Paracetamol + NSAIDs with PPI cover if concerned about GI bleed).
- Muscle relaxants (Diazepam, 5 to 10 milligrams)
- Local application of heat
- Manipulative therapy - Controversial treatment
- Physical modalities (traction, diathermy, exercise, US treatment, TENS) - Questionable benefit
Take Home
- Watchful waiting (6-8 weeks) ensures appropriate utilisation of resorces and reduces unnecessary radiation exposure.
- Set expectations and arrange follow up - Patient may expect some sort of imaging. Clarify this and let them know what symptoms concern you.
Further Reading
https://www.rcemlearning.co.uk/foamed/back-pain-advice-know-say/
https://www.rcemlearning.co.uk/references/lower-back-pain/
Posted by:
Lakshay Chanana
ST4 Trainee
Royal Infirmary of Edinburgh
Department of Emergency Medicine
Edinburgh
Scotland