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Back Pain, Emergency Medicine


Basics


Description


  • Low back pain (LBP):
    • Refers to pain in the area between the lower rib cage and the gluteal folds, often with radiation into the thighs
  • Sciatica:
    • Pain in the distribution of the lower lumbar spinal roots
    • May be accompanied by neurosensory and motor deficits
  • Pain classification:
    • Acute: <6 wk
    • Subacute: 6-12 wk
    • Chronic: >12 wk

Etiology


  • Nonspecific musculoligamentous source (great majority) (e.g., muscle, ligament, fascia)
  • Herniation of the nucleus pulposus
  • Degenerative joints or discs
  • Spinal stenosis
  • Anatomic abnormalities-especially spondylolisthesis
  • Fractures from trauma and osteoporosis
  • Underlying systemic diseases (minority):
    • Neoplasm
    • Infections
    • Vascular (dissection, aneurysm, and thrombosis)
    • Renal
    • GI
    • Pelvic organ pathology

Diagnosis


Signs and Symptoms


  • Musculoligamentous:
    • Poorly localized and dull back/gluteal pain without radiation past the knee.
    • Usually no objective neurologic signs.
    • Back spasm is a variable and poorly reproducible finding.
  • Sciatica:
    • Sharp, shooting, well-localized pain
    • Leg complaints often greater than back
    • May present with
      • asymmetric deep tendon reflexes
      • decreased sensation in a dermatomal distribution
      • objective weakness
  • Massive central disc herniation (cauda equina):
    • Decreased perineal sensation
    • Urinary retention with overflow incontinence
    • Fecal incontinence
  • Infectious processes:
    • Fever
    • Localized percussion tenderness of the vertebral bodies
  • Bony lesion:
    • Continuous pain that does not change with rest
    • Constitutional symptoms
  • Vascular etiology:
    • Severe, often "ripping or tearing"Ł pain
    • May be associated with cold or insensate extremities

History
  • Can assist with focusing and narrowing differential diagnosis. Helps rule out concerning pathology for pain:
    • Intensity
    • Quality
    • Location and radiation
    • Onset
    • Exacerbating or remitting factors
    • Social or psychological factors
    • Response to previous therapy
  • Risk factors for serious disease:
    • Fever
    • Constitutional symptoms
    • Trauma
    • Age >60 yr
    • History of cancer:
      • Especially those that metastasize to bone
    • Chronic steroid use
    • IV drug use
    • Recent instrumentation or bacteremia
    • Night pain

Physical Exam
  • Fever
  • Spasm or soft tissue tenderness is a poorly reproducible finding:
    • Vertebral tenderness sensitive but nonspecific for infection
  • Straight leg raise-elevating the leg while supine reproduces sciatic symptoms:
    • Ipsilateral raise highly sensitive but not specific
    • Crossed leg raise highly nonspecific but insensitive
  • Ankle and great toe dorsiflexion and ankle plantar flexion (L5, S1 nerve roots)
  • Ankle deep tendon reflexes (S1)
  • Dermatomal sensory exam:
    • Assess for saddle anesthesia
  • Rectal sphincter tone

Essential Workup


  • Thorough history and physical exam, including detailed neurologic and vascular exam
  • No specific tests are needed for uncomplicated musculoligamentous or sciatic pain
  • Rapid diagnostic testing and vascular consultation concerning aortic etiology

Diagnosis Tests & Interpretation


Lab
  • Urinalysis for suspected:
    • UTI/pyelonephritis
    • Prostatitis
  • ESR:
    • Highly sensitive, though nonspecific for infectious or inflammatory etiologies
    • Used for screening to help rule out disease

Imaging
  • Lumbosacral radiograph:
    • Significant trauma
    • Age >50-60 yr
    • History or signs/symptoms of cancer
    • Fever
    • IV drug user
    • Pain at rest
    • Suspicion of inflammatory etiology
    • Pain that does not improve after 4 wk
  • Bedside US:
    • Full bladder suggests urinary retention
    • Abdominal aortic aneurysm (AAA)
    • Abdominal CT if patient stable
  • MRI:
    • Suspicion of abscess:
      • Fever, immunocompromised, IVDA, history of bacteremia
    • Suspicion of metastatic tumor:
      • Systemic cancer, weight loss
    • Suspicion of hematoma:
      • Anticoagulation, recent spinal anesthesia
    • Rapidly progressing neurologic symptoms
    • Urinary retention or fecal incontinence associated with back pain
  • CT:
    • Secondary modality for diagnosis of abscess, cancer, or massive disc when MRI unavailable
    • Test of choice in imaging potential unstable fractures
    • Excellent sensitivity to evaluate vascular etiology in stable patient

Differential Diagnosis


  • Spinal origins-in the majority of patients no precise anatomic site is discovered:
    • Musculoligamentous (majority)
    • Discogenic
    • Fracture
    • Spondylolisthesis
    • Ankylosing spondylitis
    • Osteomyelitis
    • Epidural abscess/hematoma
    • Neoplasm
  • Nonspinal causes:
    • AAA
    • Prostatitis
    • Upper UTI
    • Abdominal neoplasm
    • Renal colic
    • Aortic dissection

Treatment


Pre-Hospital


  • Immobilization is not generally recommended for nontraumatic pain.
  • Rapid transport for vascular concerns

Ed Treatment/Procedures


  • NSAIDs:
    • Musculoligamentous pain
    • Renal colic
    • Similar benefits as APAP but less optimal side-effect profile
  • APAP: Considered 1st-line therapy for mild-to-moderate pain
    • Moderate but conflicting evidence for benefit of NSAID and acetaminophen combination over each individually in postoperative pain
    • APAP and NSAIDs not effective for sciatica pain
  • Muscle relaxants:
    • Cyclobenzaprine, methocarbamol, carisoprodol, or tizanidine
    • Benefits must be balanced by side effects, mostly sedation, dizziness, and dry mouth
  • Benzodiazepines:
    • No clear difference from skeletal muscle relaxants
    • Likely higher risk profile for addiction
  • Narcotics:
    • A reasonable (3-5 days) course may be given for severe pain not relieved by anti-inflammatory or APAP. Effective for neuropathic pain
    • Risk benefit profile should be considered and discussed with patient
  • Corticosteroids:
    • No benefit in radicular or nonradicular back pain
  • Spinal manipulation:
    • A short course (<2 wk) may be helpful in acute LBP without sciatica
  • Physical therapy/exercise:
    • No clear consensus for indications
    • May be helpful in symptomatic relief, preventing further episodes and teaching patients
  • Acupuncture:
    • Controversial, probable benefit for chronic musculoskeletal pain
    • No clear benefit over other modalities
    • Trigger point therapy with minimal to no evidence of benefit for chronic LBP not studied for acute
  • Massage:
    • May be beneficial when combined with exercises and education
  • Heat/cold therapy:
    • Limited evidence to support that heat wrap therapy may help reduce pain and disability for patients with back pain <3 mo. Improved as adjunct to exercise.
  • Bed rest:
    • Unhelpful to speed recovery and may impede improvement. If patient requires bed rest acutely or is symptomatically improved, 1 or 2 days may be recommended.
  • Back exercises:
    • Unlikely to be useful in acute phase; may assist with prevention of future episodes
  • Expected recovery to pain-free state:
    • Conflicting data, mostly in non-ED setting
    • ~33% within 1 wk
    • ~90% within 6-8 wk
    • Low SES, female sex, baseline disability and chronic LBP significant for worse functional outcome at 1 and 3 wk
    • Newer ED data suggests functional limitation in 50% of patients with pain at 3 mo.
  • Recurrence is common: ~40%

Medication


First Line
  • Acetaminophen: 500 mg (peds: 10-15 mg/kg, do not exceed 5 doses/24h) PO q4-6h, do not exceed 4 g/24h
  • Hydrocodone/acetaminophen: 5/500 mg PO q4-6h
  • Ibuprofen: 600-800 mg PO q6-8h (peds: 10 mg/kg q6h)
  • Naproxen: 250-500 mg PO q12h
  • Oxycodone/acetaminophen: 5/500 mg PO q4-6h

Second Line
  • Cyclobenzaprine: 5-10 mg PO TID. Caution patient regarding drowsiness.
  • Methocarbamol: 500-1,500 PO q6h. Caution patient regarding drowsiness.
  • Valium: 5-10 mg PO q8h
  • You may combine 1st- and 2nd-line therapies but side-effect profile will increase

Follow-Up


Disposition


Admission Criteria
  • Severe pain with inability to ambulate
  • Pain unresponsive to ED management
  • Progressive neurologic deficits
  • Signs of cauda equina syndrome
  • Infectious, vascular, or neoplastic etiologies

Discharge Criteria
Uncomplicated presentation with ability to control pain and ambulate á
  • Maintain a high suspicion for serious disease including vascular etiology, neoplasm, or infection.
  • Have a low threshold for imaging or diagnostic testing.
  • Follow up patients on NSAIDS or opioids more carefully for complications or adverse events related to therapy.

  • Back pain is unusual in the pediatric patient; a high suspicion for an infectious etiology must be maintained.
  • For musculoligamentous pain, a single trial found that Ibuprofen provides good pain control with a low side-effect profile.

Limited evidence suggests that strengthening and pelvic tilt exercises combined with routine prenatal care may have benefit in treating back pain; unclear if they prevent pain á
Issues for Referral
Urgent neurosurgical or orthopedic consultation for definite diagnosis or high suspicion for abscess or lesion (disc, neoplasm, or other) with rapidly progressive objective neurologic findings á

Follow-Up Recommendations


  • Uncomplicated back pain: PCP in 1-2 wk
  • New sciatica without neurologic findings: PCP or specialist in 7-10 days
  • Complicated with sensory findings only or minimal motor symptoms: 24-48 hr
  • Marked or rapidly progressive motor symptoms, or bowel/bladder findings warrant specialist consultation in the ED or transfer if unavailable.

Pearls and Pitfalls


  • Consider MRI for history of IVDA to rule out epidural abscess or if concerns of nonbony spinal metastases.
  • Elderly with minimal trauma may sustain fractures.
  • Consider vascular etiology in elderly patients with 1st-time presentation of back pain.
  • Advise patients that this is often a prolonged course and they should not expect rapid resolution.
  • Opioids should be limited to a short course from the ED.

Additional Reading


  • Cantrill áSV, Brown áMD, Carlisle áRJ, et al. American College of Emergency Physicians Opioid Guideline Writing Panel. Clinical policy: Critical issues in the prescribing of opioids for adult patients in the emergency department. Ann Emerg Med.  2012;60(4):499-525.
  • Davies áRA, Maher áCG, Hancock áMJ. A systematic review of paracetamol for non-specific low back pain. Eur Spine J.  2008;17:1423-1430.
  • Friedman áBW, O'Mahony áS, Mulvey áL, et al. One-week and 3-month outcomes after an emergency department visit for undifferentiated musculoskeletal low back pain. Ann Emerg Med.  2012;59(2):128-133.
  • Roelofs áPD, Deyo áRA, Koes áBW, et al. Nonsteroidal anti-inflammatory drugs for low back pain. Spine.  2008;33(16):1766-1774.
  • Waterman áBR, Belmont áPJ Jr, Schoenfeld áAJ. Low back pain in the United States: Incidence and risk factors for presentation in the emergency setting. Spine J.  2012;12(1):63-70.

Codes


ICD9


  • 724.2 Lumbago
  • 724.3 Sciatica
  • 724.5 Backache, unspecified

ICD10


  • M54.5 Low back pain
  • M54.9 Dorsalgia, unspecified
  • M54.30 Sciatica, unspecified side
  • M54.40 Lumbago with sciatica, unspecified side
  • M54.31 Sciatica, right side
  • M54.3 Sciatica
  • M54.41 Lumbago with sciatica, right side
  • M54.42 Lumbago with sciatica, left side
  • M54.4 Lumbago with sciatica

SNOMED


  • 161891005 backache (finding)
  • 279039007 low back pain (finding)
  • 278862001 acute low back pain (finding)
  • 278860009 chronic low back pain (finding)
  • 23056005 Sciatica (disorder)
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