C3: Chief Complaint Considerations - Back Pain - Amye Farag, MD
Chief Complaint Considerations, or C3, will give you a breakdown of the most important things to ask and look for when evaluating a particular chief complaint in the emergency department. These posts will be similar to our Deep Dive posts but will focus on a common complaint.
Back Pain is a common chief complaint presenting to the emergency department. The jobs of an emergency physician are to ensure that the etiology of the back pain does not need to be addressed immediately and to make our patients feel better. This complaint is the second highest cause of lost time in the workplace and an enormous source of health care expenditures and lost productivity.
Important questions to ask:
what were you doing when it started?
exactly where is the pain?
How long has this been going on?
Do you have any weakness or sensation loss?
Any past medical history? Specifically, cancer, bleeding disorders, sickle cell anemia?
Red Flags (a "yes" to any of these places the patient at higher risk for a serious cause of their pain):
Hx of trauma
Hx of unexplained weight loss
Neurologic symptoms (new or progressive weakness/difficulty walking, bowel or bladder incontinence, saddle anesthesia)
Age > 50
IV drug abuse
Prolonged use of steroids
Local back injections
Hx of Cancer
Pain worse at night or with laying flat
Blood thinner use
Palpation of the back to evaluate for focal tenderness
Thorough neurologic exam including strength, sensation, evaluation of saddle anesthesia, and REFLEXES
Straight leg test and crossed straight leg test
Positive straight leg test of the affected leg in lumbar radiculopathy has a HIGH SENSITIVITY but LOW SPECIFICITY for herniated disc. Positive crossed straight leg test has a HIGH SPECIFICITY but LOW SENSITIVITY for herniated disc. Bottom line: RAISE BOTH LEGS!
Gait exam (get them to walk normally, on their heels, and on their tip toes)
Abdominal exam for pulsatile masses, femoral and DP pulses
Can’t miss diagnoses in the ED
Cauda equina syndrome
Epidural abscess or hematoma
Ruptured or expanding aortic aneurysm
Spinal fracture or subluxation with cord or root impingement
Stable vs unstable?
If unstable: consider diagnoses such as dissection, AAA, sepsis (IV, O2, monitor, fluids, EKG, bedside US, stat imaging, medications as clinically indicated)
If stable: new neuro sx? Probably warrants ED MRI and neurology or neurosurgery consultation
No red flags? Supportive care, outpatient f/u
Concerned about infection? CBC, CRP, ESR
Urinalysis might be helpful to evaluate for renal colic or urinary tract infection
Plain films: Only if you are worried about fractures/pathologic lesions such as loss of vertebral height or lucencies concerning for cancer
CT scans: Great for evaluating vertebra and bony structures, not good to evaluate for infections or spinal cord injuries
MRI: Good for evaluating for tumors, infection, spinal cord pathology
US: abdominal to evaluate for AAA
NSAIDs (careful with elderly and kidney disease patients)
Trigger point injections
Short term course of steroids (the literature on steroids in back pain shows modest benefit in pain and decreased recovery time in patients with RADICULAR symptoms; however, no significant benefit in primary back pain alone. Consider it in your sciatica cases, but avoid in poorly controlled diabetics)
Severe pain: consider short term narcotics
Bedrest shows delayed time in return to function, encourage light exercise (frequent walks and gentle stretching)
Editor’s Commentary by Dr. Alex Dzurik:
Back pain can often be the bane of the emergency physician. The vast majority of back pain will be benign but the complaint is rife with landmines that are very easy to fall onto. As added fun, the majority of available treatments do little to improve the natural course of back pain and most will resolve spontaneously within 2 weeks, while a minority will persist no matter what you do for treatment in the emergency department.
Remember every patient over 50 with back pain should be at least considered for abdominal aortic aneurysm, and bedside ultrasound should be employed unless patient has had an abdominal CT within the past 1-2 years.
Cauda equina has a significant rate of functional impairment and is highly associated with malpractice cases; however, it is on average diagnosed on the third ED visit. Neurologic findings are a delayed presentation and often the damage is permanent by the time they manifest. Careful history-taking, looking for risk factors, and maintenance of a high index of suspicion with said risk factors remains the best way to avoid failures of diagnosis.
The importance of the neurologic exam (looking particularly at sensation, reflexes, and ambulation of the patient) cannot be overstated. Documentation of these findings should be seen on every back pain chart. The ED physician must maintain constant vigilance and not fall into the trap of “it’s just back pain” when walking into the room.
References and other great resources to check out:
Marx, J. A., & Rosen, P. (2014). Rosen's emergency medicine: Concepts and clinical practice (8th ed.). Philadelphia, PA: Elsevier/Saunders.
Thanks to Physiotutors for the video tutorials
Post peer-reviewed by: Alex Dzurik, MD; Academic Faculty, Mercy Health St. Vincent’s Emergency Medicine Residency