Back Pain (2024)

by Paila Naveen & Manjith Reddy

You have new patients!

A 30-year-old male patient presents to the ED with an abnormal gait and no history of comorbidities. He complains of low back pain that started three days ago after performing a deadlift during a gym competition. The patient reports experiencing a snapping sensation during the lift, followed by a shooting pain radiating down the left leg, which subsided after a short time. However, the low back pain gradually worsened over the past three days and became unbearable upon arrival. He also reports weakness in the left foot since this morning, making it difficult for him to walk properly. This concern prompted him to seek medical attention in the ED.

What do you need to know?

Importance

Back pain is a term that, while commonly used, oversimplifies a condition affecting a much larger area of the body. It is often not taken seriously, possibly due to the time-consuming nature of evaluation, a lack of proper clinical skills, inadequate anatomical knowledge, or the pressures of a busy emergency department. This oversight can result in difficulty accurately identifying the cause of the pain, ultimately leading to increased morbidity and mortality.

This approach must change, as underestimating back pain can have fatal consequences. The condition encompasses a wide spectrum of causes, ranging from a minor muscle strain to severe conditions such as cauda equina syndrome, aortic dissection, or even worse.

Epidemiology

Up to 84% of adults experience low back pain at some point in their lives [1]. It is one of the top five most common complaints in emergency departments (ED) [2]. Low back pain accounts for 3.15% of all ED visits, with 65% of these cases resulting from injuries sustained at home [3]. Despite its prevalence, an estimated 85% of patients presenting with low back pain cannot be accurately diagnosed; however, nearly all of these patients recover within 4–6 weeks [4]. In contrast, 5–10% of patients with acute back pain suffer from more serious underlying conditions. While most visits for back pain are benign, they can be time-consuming and frustrating for both physicians and patients. Emergency physicians must remain vigilant in identifying and managing potentially dangerous conditions [5].

Pathophysiology

Acute back pain is a multifaceted condition characterized by various underlying mechanisms that contribute to its pathophysiology. It typically arises from damage to somatic structures, leading to nociceptive pain, which is transmitted through the peripheral and central nervous systems [6]. The pathophysiology of back pain involves multiple structures, including peripheral nerves, the central spinal cord, skeletal muscles, and blood vessels spread across the back. These structures can be affected by various underlying causes, broadly categorized as vascular, structural, referred pain, inflammation, infection, metabolic disorders, neoplasms, or trauma.

Acute back pain primarily involves nociceptive pathways, which transmit pain signals from damaged tissues such as the lumbar spine, ligaments, and muscles. In many acute cases, muscle spasms significantly contribute to pain; however, there is ongoing debate regarding whether these spasms are a primary cause or a secondary response to the injury. The progression from acute to chronic pain often involves central sensitization, a process where the nervous system becomes increasingly sensitive and responsive to pain stimuli [6].

When assessing a patient, it is crucial to first evaluate the nature of the pain. Determine whether the pain is localized, which may indicate an underlying fracture, or diffuse, as seen in conditions like an epidural abscess. Consider the possibility of referred pain originating from retroperitoneal structures. Additionally, assess for systemic symptoms or signs of inflammation, such as weight loss, which could point to a neoplasm or other serious pathology.

A thorough history-taking process is essential, including both positive and negative findings, to narrow down the differential diagnosis. Employ a structured approach to guide your assessment; once you refine the differential through history and clinical examination, investigations can confirm the diagnosis and facilitate effective management.

Initial Assessment and Stabilization

As emergency physicians, our approach to back pain differs from that of other specialties, as we must remain highly alert and responsive. While stable cases allow for a thorough history to be taken, unstable patients require a critical and focused approach to quickly identify the underlying cause. The following outlines this critical approach:

Airway/Breathing

When assessing a critical patient, prioritize airway and breathing management, and prepare for intubation. Key considerations include proper positioning, adequate suctioning, aspiration prevention, and effective visualization while securing the airway. Use videolaryngoscopy for improved visualization unless visualization is expected to be poor. To minimize aspiration risk, avoid over-ventilation and ensure the availability of two high-volume suction devices. Refrain from placing the patient in a supine or prone position to further reduce aspiration risk. Enhance first-pass success by using a bougie, and place a nasogastric tube once the airway has been secured.

Circulation

In patients with undifferentiated back pain presenting in shock, apply standard shock management measures. Begin with the insertion of two large-bore IVs to establish access for fluid and blood administration. If conditions such as abdominal aortic aneurysm (AAA), retroperitoneal hemorrhage, or ruptured ectopic pregnancy are suspected, cross-match for six units of blood. For suspected spinal epidural abscess, obtain blood cultures, administer appropriate antibiotics, and consider vasopressors if the patient remains unresponsive to a fluid bolus of 30 mL/kg. Use point-of-care ultrasound to assess the aorta for AAA and evaluate the bladder for urinary retention, particularly if cauda equina syndrome is a concern. Residual urine volumes greater than 100–150 mL are abnormal. Ultrasound is the preferred method for screening urinary retention due to its accuracy, non-invasiveness, and patient comfort, though a Foley catheter can also be used to measure residual urine volume [7].

The assessment of neurological status and additional exposure findings should be completed during the initial evaluation of the undifferentiated unstable back pain patient.

Medical History

A comprehensive history is essential when evaluating patients with back pain. The acronym SOCRATES provides a structured approach to effectively assess the nature of the pain:

SITE: Determine the exact location of the pain.
ONSET: Enquire about when and where the pain initially started.
CHARACTER: Ask about the quality of the pain, such as pricking, stabbing, burning, or squeezing. Pain at rest, accompanied by sweating or sleep disturbance, is often associated with conditions like rheumatoid arthritis, ankylosing spondylitis, or malignancies. Burning pain usually indicates neuropathy, while tearing pain may suggest aortic dissection. Sharp, shooting pain with localized tenderness may indicate spinal fractures, muscle spasms, or pulmonary embolism.
RADIATION: Explore whether the pain radiates to specific regions. For instance, cervico-genic headaches can radiate to the head, chest pain may suggest myocardial infarction or aortic dissection, and radiculopathy often involves the upper or lower limbs due to nerve root compression. Loin-to-groin radiation is characteristic of renal colic, while pain extending to the buttocks or legs may point to sciatic nerve compression. Abdominal radiation is commonly associated with constipation, mesenteric ischemia, or an abdominal aortic aneurysm (AAA).
ASSOCIATED SYMPTOMS: Enquire about symptoms accompanying back pain. Important symptoms to explore include sensory or motor deficits (indicating nerve root or spinal cord compression, such as in radiculopathy or cauda equina syndrome), urinary retention or incontinence (specific to cauda equina syndrome), hematuria (suggestive of kidney injury or malignancy), fever (associated with epidural or spinal abscesses), weight loss (indicative of malignancy), and morning stiffness (linked to rheumatoid arthritis or ankylosing spondylitis) [7].
TIME COURSE: Assess how the pain has evolved over time and use a pain severity scale (1–10) to gauge its intensity.
EXACERBATING OR RELIEVING FACTORS: Ask about factors that worsen or alleviate the pain, such as coughing, sneezing, walking, lying down, compression, medications, or physical support.
SEVERITY: Beyond numerical scales, explore how the pain impacts the patient’s daily activities and ability to perform routine tasks.

A thorough patient history should include surgical, family, medication, and social factors that may contribute to back pain.

Surgical history should document any previous back procedures, as they may influence the current presentation.

Family history is essential to identify any hereditary predisposition to vascular or inflammatory diseases.

Medication history should include the use of immunosuppressive therapies, anticoagulants, or glucocorticoids, as these can increase the risk of infections, bleeding, or osteoporosis-related complications.

Finally, social history should explore lifestyle factors such as intravenous drug use, alcohol consumption, smoking, and pregnancy status, all of which can significantly impact the diagnosis and management of back pain.

Special attention should be given to traditional “red flag” symptoms for back pain during the patient history, as these symptoms often warrant immediate imaging in the emergency department.

These red flags can be remembered using the mnemonic TUNA FISH [8]:

T for trauma,
U for unexplained weight loss,
N for neurological symptoms,
A for age over 50 years,
F for fever,
I for IV drug use or immunocompromised status,
S for steroid use or syncope, and
H for a history of cancer.

Physical Examination

A thorough physical examination is essential for patients presenting with undifferentiated back pain, especially when red flags are not evident in the history. It is critical to carefully evaluate for red flags during the examination and document all findings meticulously. The red flags on examination include abnormal vital signs (e.g., hypotension, fever, tachycardia, hypoxemia, or pulse deficits), motor weakness, saddle anesthesia, urinary retention, loss of rectal tone, abnormal reflexes (such as a positive Babinski sign), and pain on percussion of the spinous processes. In addition to identifying red flags, the physical examination should also cover other key areas to narrow the differential diagnosis.

Key Components of the Physical Examination:

Red Flags for Back Pain:

Abnormal vital signs: Hypotension, fever, tachycardia, hypoxemia, pulse deficits.
Motor weakness.
Saddle anesthesia.
Urinary retention.
Loss of rectal tone.
Abnormal reflexes: Positive Babinski sign.
Pain on percussion of spinous processes.

Other Important Aspects:

Inspection:
- Examine the back for signs of trauma, infection, asymmetry, scoliosis, kyphosis, or herpes zoster.
- Assess hip, pelvis, and spine anatomy and function.
Percussion/Palpation:
- Check for vertebral or soft tissue tenderness.
- Palpate for pulsatile abdominal masses.
Neurologic Examination:
- Assess reflexes (e.g., diminished or abnormal knee and plantar reflexes).
- Evaluate strength (weakness in the upper or lower extremities).
- Observe gait, ataxia, limp, or inability to ambulate.
- Check for signs of cauda equina syndrome, including loss of rectal tone or sensation.
Testing for Sciatic Nerve Root Irritation:
- Perform straight leg raising tests.
- Look for bilateral weakness, paresthesia, sensory level abnormalities, saddle anesthesia, muscle atrophy, and decreased rectal sphincter tone.
Vascular Assessment:
- Measure upper extremity blood pressures for discrepancies (e.g., aortic dissection).
- Listen for murmurs (aortic insufficiency) or signs of peripheral vascular disease [9].
Genitourinary Examination:
- Assess for urinary retention or incontinence.
- Measure post-void residual (abnormal if >100 mL).
- Perform a prostate exam if appropriate, considering prostatic hypertrophy as a possible cause of retention.
Rectal Examination:
- Conduct a rectal exam in all high-risk patients to assess for abnormalities in tone or sensation.

Additional Considerations:

Repeat the neurological exam throughout the encounter to detect any changes or progression in symptoms.
Remember that the spinal cord ends at L1; herniation above this level results in upper motor neuron findings (e.g., weakness, hyperreflexia, increased tone), while herniation below L1 leads to lower motor neuron findings (e.g., weakness, hyporeflexia, atrophy).
Consider the psychosocial context of lower back pain. Inconsistencies in physical findings due to patient distraction should not be dismissed as malingering. Instead, view these inconsistencies as the patient’s way of seeking help, just as with any other presentation.

Special examinations for back pain, often referred to as provocative tests, are used to assess specific conditions or structures causing discomfort. These include the Straight Leg Test, which evaluates nerve root irritation, commonly associated with lumbar disc herniation [10]. A variant of this test may be performed to refine diagnostic accuracy. The Tripod Sign Test assesses hamstring tightness and its relation to nerve irritation or musculoskeletal dysfunction [11]. Lastly, the Femoral Stretch Test is used to identify pathology in the femoral nerve or upper lumbar nerve roots [12]. Together, these tests provide targeted insights into the underlying causes of back pain.

Primary Goal

The primary goal when evaluating back pain is to rule out life-threatening, non-spinal causes. These include acute aortic aneurysm (AAA), thoracic aneurysm, aortic dissection, ectopic pregnancy, and epidural compression from abscess or hemorrhage. Once these critical conditions are excluded, attention should shift to nonspecific low back pain, which may originate from nerves, nerve roots, musculoskeletal structures, or even nonorganic causes. During the rapid physical examination, the presence of red flag signs should prompt immediate concern. These warning signs include abnormal vital signs, motor weakness, saddle anesthesia, urinary retention, loss of rectal tone, abnormal reflexes, and pain on percussion of the spinous processes.

Not-to-Miss Diagnoses and Red Flags

DIAGNOSIS	RED FLAG`S
Acute aortic pathology	Pain abdomen Blood in urine Pulse deficit in extremities Abdominal bruit/thrill Palpable abdominal mass
Infection (Spinal epidural abscess, Discitis, Osteomyelitis)	Fever Intra venous drug use Immunodeficiency/HIV Diabetes Steroid use
Fracture (Traumatic, Pathologic)	Recent fall/trauma, Age > 60yrs Previous traumatic fracture Spinal tenderness
Malignancy (Primary / metastasis)	Unusual Weight Loss Night sweats Fatigue Chronic pain H/O cancer Pain unresponsive to analgesia
Cauda Equina Syndrome/Disc Herniation	Weakness Loss of sensation Decreased reflexes Inability to walk Bowel & Bladder incontinence Bladder distension

Alternative / Differential Diagnoses

When evaluating patients with back pain, it is crucial to consider a broad differential diagnosis encompassing various systemic and localized causes. Back pain may arise from vascular, infectious, mechanical, immunologic, rheumatologic, inflammatory, non-organic, or pharmacologic origins. Each category includes potentially life-threatening and benign conditions that require careful assessment. By systematically approaching the possible causes, clinicians can better identify the underlying pathology and prioritize interventions based on the severity and acuity of the patient’s presentation. The following is a categorized list of potential diagnoses to guide clinical evaluation and management.

Vascular Causes

Abdominal aortic aneurysm
Acute coronary syndromes
Acute vaso-occlusive crisis
Cardiac tamponade
Severe aortic insufficiency/regurgitation
Thoracic aortic dissection
Pulmonary embolism
Renal artery dissection or thrombosis
Retroperitoneal hematoma
Spinal/epidural hematoma

Infectious Causes

Discitis
Epidural abscess
Meningitis
Osteomyelitis
Pelvic inflammatory disease
Pericarditis
Pneumonia
Prostatitis
Pyelonephritis
Tuberculosis (Pott’s disease)

Mechanical Causes

Cauda equina syndrome (from disc herniation or fracture)
Disc herniation
Ectopic pregnancy
Lumbar radiculopathy
Metastatic cancer
Pneumothorax
Pneumomediastinum
Scoliosis
Spinal stenosis
Syringomyelia
Traumatic or pathologic vertebral fracture
Ureteral calculus

Immunologic Causes

Transverse myelitis

Rheumatologic Causes

Gout and pseudo-gout
Osteoarthritis
Rheumatoid arthritis

Inflammatory Causes

Cholecystitis
Herpes zoster
Myocarditis/pericarditis
Musculoskeletal strain
Pancreatitis
Perforated viscus

Non-organic Causes

Factitious disorder
Depression

Pharmacologic Causes

Tolerance, dependence, addiction

Acing Diagnostic Testing

When life-threatening, non-spinal causes of low back pain have been ruled out through history and physical examination, laboratory tests are generally unnecessary for most patients. However, there are specific situations where laboratory investigations may provide valuable diagnostic insight [13,14]. These include cases where infection, malignancy, immune suppression, or other red flags are suspected. Below is a list of relevant laboratory tests and their clinical significance:

Laboratory Tests for Low Back Pain:

Complete Blood Count (CBC):

Helps identify infection, malignancy, or immune suppression.
Elevated white blood cell counts are present in only 66% of patients with spinal epidural abscesses [15].

C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR):

These markers may aid in diagnosing inflammatory or malignant conditions [16].
Elevated levels are associated with osteomyelitis and discitis [17].
Due to poor sensitivity, CRP and ESR are not recommended for patients without red flags and are not typically used when disc herniation or epidural hematoma is the primary diagnosis [18].

Pregnancy Testing:

Should be performed on all women of childbearing age to rule out pregnancy-related causes and guide management.

Radiographic Examination for Back Pain

Radiographic examination is crucial for evaluating, interpreting, and reviewing patients experiencing back pain due to spinal issues. This section discusses the use of various imaging modalities and diagnostic tools to assess potential life-threatening and spinal-related conditions.

Point-of-Care Ultrasound

Point-of-care ultrasound (POCUS) is a rapid bedside diagnostic tool that allows for quick and accurate detection of various emergency conditions. It aids in deciding whether further imaging is necessary.

Cardiac Ultrasound: Perform a cardiac ultrasound to detect ascending aortic dissection and pericardial effusion. Use the sub-xiphoid view and evaluate:
1. Pericardial effusion
2. Right atrial (RA) and diastolic right ventricular (RV) collapse
Additionally, the physical examination should include checking for pulsus paradoxus.
Parasternal – long axis view provide information about ascenting aorta and possible aortic dissection.
Abdominal Aortic Ultrasound: Perform this ultrasound to rule out abdominal aortic aneurysm (AAA).
Targeted Ultrasound for Trauma: Examine for free fluid in the pelvis and, if a ruptured ectopic pregnancy is suspected, include the uterus and adnexa in the evaluation.
Suspected Cauda Equina Syndrome: Conduct a residual urine test, as urinary retention (>100-150 mL) is abnormal. Ultrasonography of the bladder is preferred to calculate residual urine volume because it is accurate, noninvasive, and more comfortable for the patient. Alternatively, a Foley catheter can be used to measure residual urine after urination. [19]

Chest Radiograph

A chest radiograph is a valuable tool for identifying emergency causes of back pain, including:

Dilated mediastinum (indicative of thoracic aortic dissection)
Pneumothorax
Pneumomediastinum
Free air under the diaphragm (suggestive of a perforated viscus)

Once life-threatening non-spinal causes of back pain have been excluded, imaging can be ordered based on prominent symptoms and findings from the patient’s history and physical examination. The primary imaging modalities include plain radiographs, computed tomography (CT), and magnetic resonance imaging (MRI). [20]

Plain Radiographs

Plain radiographs have limited diagnostic utility but can be helpful in specific situations:

Fracture Detection: Anterior-posterior and lateral radiographs may identify vertebral fractures, although they are less sensitive than CT scans.
Infection or Malignancy: When combined with erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) tests, plain radiographs can reduce the likelihood of infection or malignancy.
Incidental Fractures: Plain radiographs may also reveal incidental fractures.

Computed Tomography (CT)

CT provides better resolution and higher sensitivity/specificity than plain radiographs. It is especially useful for suspected spinal fractures. However, CT has limitations:

It does not adequately image the spinal cord, making it less effective for diagnosing epidural abscesses and disc herniations.
Consider CT only when MRI is contraindicated. [21]

Magnetic Resonance Imaging (MRI)

MRI is the imaging modality of choice for urgent spinal conditions, including:

Spinal/epidural hematomas
Epidural abscesses
Cauda equina syndrome
Transverse myelitis
MRI Without Contrast: This provides detailed imaging of intervertebral discs, canal anatomy, nerves, ligaments, and epidural fat. Clinical guidelines recommend early MRI for uncomplicated occupational low back pain only if red flags are absent [21].
MRI With Gadolinium Contrast: Adding gadolinium improves diagnostic accuracy by differentiating surgical scarring from disc disease and evaluating vascular function in real-time.

Myelography

Myelography may be used in patients unable to undergo MRI. It evaluates the spinal cord, nerve roots, and meninges, offering a valuable alternative in specific cases.

Management

Approach To the Non-Critical Patient

Providing care to non-critical patients with back pain involves early pain management, targeted therapy, and continuous evaluation for red flags. This approach enhances patient satisfaction and ensures effective management.

Early Pain Management

Early analgesia is a critical aspect of care. Non-narcotic analgesics are preferred, combined with an empathic attitude from healthcare providers. These measures significantly improve patient comfort and satisfaction. [22]

Targeted Therapy

Treatment should be aimed at addressing the specific underlying cause of the back pain. Common conditions to consider include:

Lumbar Radiculopathy
Sciatica with Nerve Root Compression
Spinal Stenosis
Musculoskeletal Strain
Scoliosis

However, it is important to note that the majority of patients (approximately 85%) experience nonspecific back pain without a readily identifiable underlying condition. [23]

Reevaluation and Multidisciplinary Approach

Patients with persistent back pain should be reevaluated for red flags that may indicate serious underlying conditions. In the absence of red flags:

Initiate appropriate treatment tailored to the patient’s symptoms.
Consider referral to a physician for further evaluation and management as needed.
A multidisciplinary approach, involving physical therapy, pain management specialists, and other healthcare providers, may provide additional benefits for long-term management.

Non-Pharmacologic Management

Non-pharmacologic interventions play an essential role in managing back pain, particularly in acute, subacute, and chronic stages. These methods are effective, safe, and recommended by guidelines to complement or substitute pharmacologic treatment.

Heat Therapy

According to the 2017 American College of Physicians guidelines, superficial heat therapy is recommended as a form of nonpharmacologic analgesia for back pain. It provides relief by improving blood flow and relaxing muscles, making it an effective first-line treatment for many patients.

Activity Recommendations

Acute Phase: Patients should remain as active as possible. While engaging in structured exercise is not advised during the acute phase, maintaining light activity is beneficial. [24]
Bed Rest: Patients who remain on bed rest tend to recover more slowly and report more pain compared to those who stay ambulatory. Encouraging mobility helps expedite recovery. [25]

Exercise for Subacute and Chronic Pain

For patients with subacute or chronic low back pain, engaging in regular physical activity is crucial for long-term management. No specific type of exercise has proven superior; instead, various forms can be beneficial, including:

Aerobic exercise
Stretching
Pilates
Walking
Yoga
Tai Chi

The choice of activity should be tailored to the patient’s preferences and physical capacity to ensure adherence and maximize benefits. [26]

Trigger Point Injection Therapy

Trigger point injection therapy is a valuable but often underappreciated treatment for managing regional musculoskeletal pain. This therapy targets specific areas of muscle tightness, commonly associated with myofascial pain syndrome.

Characteristics of Trigger Points

A trigger point is a localized area of muscle pain that typically worsens with movement. These points are often identified during physical examination by the presence of a “twitch” response or the radiation of pain upon palpation. [27]

Pathogenesis of Trigger Points

The exact scientific mechanism behind the formation of trigger points remains unclear. However, many researchers suggest that acute trauma or repetitive microtrauma plays a significant role. Several contributing factors have been identified, including:

Suboptimal physical conditioning
Surgical scars
Insomnia
Joint dysfunction
Vitamin deficiencies
Poor posture [28]

Application of Trigger Point Injections

Although trigger point injections are not commonly utilized in emergency department (ED) settings, they represent a safe and effective alternative to narcotic pain management. By targeting the localized source of pain, this therapy can provide significant relief, especially in patients with myofascial pain syndrome. Increased awareness of this technique may help expand its use in broader clinical practice.

Some recommended anesthetic agents and their dosage are below;

Lidocaine 1%

Dosage: The recommended dosage of lidocaine 1% is 3 mg, with a maximum allowable dose of 5 mg.
Pregnancy Considerations: Lidocaine may induce premature labor; therefore, it is essential to seek expert advice before administering it to pregnant patients.
Precautions: Ensure accurate dosing to avoid complications. Monitor for signs of local anesthetic toxicity during and after administration.

Bupivacaine 0.25%

Dosage: The standard dosage for bupivacaine 0.25% is 0.75 mg, with a maximum limit of 1.25 mg.
Pregnancy Considerations: Like lidocaine, bupivacaine may also induce premature labor, necessitating expert consultation before use in pregnant patients.
Precautions: Accurate dosing is critical. Watch for potential symptoms of local anesthetic toxicity to ensure patient safety.

Injection Procedure

When administering injections, limit the procedure to a maximum of three sites while strictly adhering to sterile technique. Inject 0.3-0.5 mL into each site, carefully infiltrating the subcutaneous and muscle tissue. It is unnecessary to approach the spine or deeper muscle layers during this process. [29]

Use of Lidocaine 5% Topical Patches

Lidocaine 5% transdermal patches may also be utilized for pain management. Patients should be advised to remove the patch every 12 hours to prevent potential skin irritation. Proper application and timing are essential to maximize effectiveness while minimizing side effects.

Non-opioid analgesics (acetaminophen and non-steroidal anti-inflammatory drugs [NSAIDs], topical analgesics)

Non-opioid analgesics are considered the first-line treatment for pain management. Among these, non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for their efficacy. However, their application must be tailored to individual patient needs and conditions.

Common NSAIDs and Their Guidelines

Ibuprofen:

- Dose: 400 mg, with a maximum of 800 mg
- Frequency: Every 6 hours
- Use in Pregnancy: Category C in the first and second trimesters
- Caution: Avoid in patients with acute kidney injury (AKI), congestive heart failure (CHF), or liver disease.

Naproxen:

Dose: 250 mg, with a maximum of 500 mg
Frequency: Every 12 hours
Use in Pregnancy: Not recommended
Caution: Use cautiously in patients with a history of stomach ulcers.

Diclofenac:

Dose: 50 mg, with a maximum of 75 mg
Frequency: Every 12 hours
Use in Pregnancy: Category C in the first and second trimesters
Caution: Avoid in patients with NSAID allergies.

Meloxicam:

Dose: 7.5 mg, with a maximum of 15 mg
Frequency: Once every 24 hours
Use in Pregnancy: Category C in the second and third trimesters
Caution: Contraindicated in patients with chronic kidney disease (CKD), chronic liver disease (CLD), or post-coronary artery bypass graft (CABG) surgery.

In clinical practice, the management of pain, particularly low back pain, often varies due to limited high-quality data. Low back pain remains one of the most common reasons patients are prescribed opioids, despite the availability of non-opioid alternatives [31,32].

Emerging data suggest that topical therapies can provide safe and effective treatment options for patients experiencing chronic, localized musculoskeletal and neuropathic pain. These therapies serve as an alternative for individuals who may not tolerate oral NSAIDs or opioids. [33]

Opioid Analgesics

Opioids are commonly used for pain relief in patients with low back pain, particularly in emergency department (ED) settings. However, their use should be carefully considered due to limited evidence of long-term benefits.

Prevalence of Opioid Use

A national study authored by Friedman revealed that opioids are administered to two out of three patients presenting to the ED with low back pain. This high prevalence highlights the reliance on opioids in acute care settings. [34]

Patient Population and Data Interpretation

Patients presenting to the ED often have more acute illnesses or severe pain compared to those seen in primary care settings. This distinction may skew the data and influence treatment patterns, as ED physicians are tasked with managing severe pain in a short timeframe.

Limitations of Opioid Therapy

Opioids provide temporary pain relief but lack evidence of improving functional outcomes or reducing long-term disability in patients with acute low back pain. For this reason, they are not recommended as first-line therapy for managing such conditions.

Appropriate Use of Opioids

Opioids should be reserved for specific scenarios:

When all other alternatives have been exhausted
When low-dose treatment can facilitate a return to mobility in the emergency setting

By reserving opioid use for carefully selected cases, clinicians can minimize the risk of dependency and prioritize treatments that improve long-term outcomes.

Muscle Relaxants

Muscle relaxants are often considered for managing muscle spasms and associated pain, but their effectiveness and appropriate use require careful evaluation.

Evidence suggests that muscle relaxants are not more effective than nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or aspirin for managing pain. These alternatives are often preferred due to their similar efficacy and more favorable safety profiles. [35, 36]

A single dose of a benzodiazepine may be considered in the emergency department (ED) for acute muscle spasms. However, benzodiazepines are categorized as second-line agents for this purpose and are not recommended for routine prescription at discharge. Limiting their use helps reduce the risk of dependency and other potential side effects.

Steroids

The role of steroids in managing low back pain remains a topic of confusion and debate. While oral steroids can provide initial symptom relief, their long-term outcomes are less favorable. Studies have shown that patients who use oral steroids may experience complicated outcomes after one year, raising questions about their routine use in this context.

Surgery

Although it is not a primary focus of emergency medicine, providing appropriate recommendations for patients based on institutional resources regarding surgical options can be valuable for their management. For patients who do not respond to pharmacologic therapy, surgical interventions may be considered. These options are typically reserved for individuals with persistent symptoms or structural abnormalities requiring correction [37].

Special Patient Groups

Pediatrics

Unlike adults, children presenting with back pain are more likely to have an underlying serious medical condition. This is especially true for children aged four years or younger, or for any child whose back pain is accompanied by concerning symptoms.

Warning Signs Associated with Back Pain in Children

Parents and caregivers should be alert to the following red flags:

Fever or Weight Loss: These symptoms may indicate an infection or systemic illness.
Weakness or Numbness: Neurological deficits can suggest nerve involvement or spinal cord compression.
Difficulty Walking: Impaired mobility may point to musculoskeletal or neurological issues.
Radiating Pain: Pain that spreads to one or both legs could signal spinal conditions.
Bowel or Bladder Problems: Issues with bowel movements or urination may indicate spinal cord dysfunction.
Sleep Disruption: Pain severe enough to prevent the child from sleeping requires urgent evaluation.

Importance of Early Diagnosis and Treatment

Serious causes of back pain in children must be identified and addressed promptly. Delayed diagnosis and treatment can lead to worsening symptoms and potentially long-term complications. Careful clinical evaluation and appropriate imaging or laboratory tests are essential to rule out conditions such as infections, tumors, or structural abnormalities. Emergency physicians should always think about possibility of child abuse and traumatic injuries in this age group.

Geriatrics

In elderly individuals, back pain requires careful evaluation due to the increased risk of fractures and other serious conditions. Vertebral fractures can occur even with minimal force, making it critical to consider the possibility of compound vertebral fractures in older patients, even in the absence of trauma.

Life-Threatening Diagnoses to Rule Out

When evaluating back pain in elderly patients, it is important to rule out life-threatening conditions that are more common in this age group, including:

Aortic Dissection: A tear in the inner layer of the aorta that can cause severe back pain.
Abdominal Aortic Aneurysm: A potentially fatal condition involving the enlargement and potential rupture of the abdominal aorta.

Common Causes of Back Pain in the Elderly

In addition to ruling out life-threatening diagnoses, healthcare providers should consider the following common causes of back pain in older adults:

Osteoarthritis: A degenerative joint condition leading to stiffness and pain in the spine.
Degenerative Disc Disease: The wear-and-tear breakdown of intervertebral discs, which can result in chronic back pain.
Facet Joint Osteoarthritis: Degeneration of the small joints in the spine, contributing to localized pain and reduced mobility.

Pregnant Patients

Back pain is one of the most common issues experienced during pregnancy, particularly in the later months. While this discomfort often subsides after childbirth, many women continue to experience back pain for months postpartum.

Common Causes of Low Back Pain and Pelvic Girdle Pain in Pregnancy

Several factors contribute to low back pain and pelvic girdle pain during pregnancy, including:

Hormonal Changes: Hormonal fluctuations can loosen ligaments and joints, leading to instability and pain in the pelvic region.
Increased Weight: The growing weight of the baby places added stress on the lumbar vertebrae, causing discomfort and strain.
Compression of the Inferior Vena Cava (IVC): As the uterus enlarges, it may compress the IVC, leading to venous congestion and associated back pain.
Poor Nutrition: Inadequate nutrition during pregnancy can weaken muscles and bones, exacerbating pain.

Serious Causes Requiring Aggressive Management

In some cases, back pain during pregnancy may indicate more serious underlying conditions that require prompt attention and treatment. These include:

Lumbar Disc Herniation
Trauma
Infections
Masses

Identifying and addressing these causes is critical to ensuring the safety and well-being of both the mother and the baby.

IV Drug Users

Patients in this category may present with isolated back pain or more severe manifestations such as full-blown sepsis, meningitis, or septic shock. Prompt recognition and thorough examination of these patients are crucial. Immediate administration of antibiotics is essential to prevent further complications and reduce the risk of long-term morbidity. Timely intervention can significantly improve outcomes in these critical cases.

When To Admit This Patient

Patients presenting with back pain may be safely discharged if all the following criteria are met:

The patient has no neurological deficits or red flag findings on physical examination.
The patient is able to ambulate without difficulty.
Pain is under control, and no emergency cause has been identified.

For patients with uncontrolled pain or inability to care for themselves, an overnight stay in a hospital observation unit or nursing facility may be required for further management [38].

Admission is warranted in patients who exhibit significant abnormalities or require specialist intervention. The following scenarios outline the need for admission and further consultation:

Abnormal Physical Examination Findings:
- Patients with abnormal signs on physical examination should be referred for emergency consultation with the appropriate inpatient service.
Vascular and Mechanical Syndromes:
- Conditions such as abdominal aortic aneurysm (AAA), vascular spinal cord syndromes (e.g., spinal or epidural hematoma), and mechanical spinal cord syndromes (e.g., cauda equina syndrome or syringomyelia) necessitate immediate consultation with vascular or spine specialists for intervention and potential admission.
Spinal Fractures:
- Patients with spinal fractures require evaluation by an orthopedic surgeon and/or neurosurgeon. Admission is determined based on the fracture’s stability and the patient’s level of pain control.
Infectious Spinal Syndromes:
- Conditions such as epidural abscesses, osteomyelitis, or discitis require admission and consultation with specialists in Infectious Diseases and Spine.
Immunologic Spinal Cord Syndromes:
- Patients with conditions like transverse myelitis should be referred to neurology for consultation and further management.

Revisiting Your Patient

Firstly, as the patient is stable, which means A, B, and C are clear, the patient should be managed for pain (pain scale 8/10). On an emergent basis, Opioid was given for rapid relief. Further examination revealed the patient had foot drop, neurological deficits, motor weakness (S1 myotome), and a decrease in left foot reflexes causing him to have a high steppage gait on arrival to ED. At this juncture, it is clear the patient is having a nerve compression as there are focal neurological deficits. Here, you can call for senior help, as neurological deficits need to be reassessed for proper documentation. MRI of the whole spine showed prolapse of the L4/L5 intervertebral disc with compression on the thecal sac and bilateral neural foramina with osseous spinal canal stenosis at the L4 L5 vertebrae. The patient was admitted according to the admission criteria described earlier in the chapter, was made to wear a lumbar belt, and received epidural analgesia with corticosteroid injection. The patient was monitored for further neurological deterioration, which did not develop. Hence, he was discharged with supportive management, including physiotherapy and follow-up.

Authors

Paila Naveen

Dr. Paila Naveen, MBBS, CCT-EM, MRCEM, SEMI (Society of Emergency Medicine India) member, Consultant in Emergency Medicine, India, has fallen in love with this specialty, which he describes as his adrenaline pump for the rest of his medical service. He has a vision to spread the word about the importance of this specialty and the full potential of an emergency physician that can be achieved with the right skills and techniques in hand to save lives and bring smiles to the world. He is a strong supporter of FOAMed and runs a site exclusively for Emergency Medicine where he teaches, discovers new things, and tries to make a difference in every step he takes forward. He spreads awareness about this branch, as it is still in its infancy in India, through every possible medium where students and other doctors are connected in a collaborative way to further enhance the beauty of EMERGENCY MEDICINE.

Manjith Reddy

Dr. Manjith K S is an emergency physician with over 4 years of experience. He completed his medical school in 2012 and his residency in emergency medicine in 2019. Passionate about providing high-quality care, Dr. Manjith is dedicated to ensuring the best possible outcomes for his patients. He stays up-to-date with the latest medical research and practices and is a strong advocate for patient safety and quality improvement. Dr. Manjith is highly skilled in quickly assessing and diagnosing patients with a wide range of conditions and is an expert in the use of emergency medical equipment and procedures. His professional interests include trauma and cardiac emergencies. In addition to his clinical expertise, he serves as a mentor to junior physicians and residents, fostering the next generation of emergency medicine professionals. As a lifetime member of the Society of Emergency Medicine India (SEMI), Dr. Manjith is committed to advancing the field of emergency medicine. He currently works as a full-time consultant for a private healthcare organization. Proud to be part of the emergency medicine community, Dr. Manjith believes that emergency physicians are the frontline of healthcare.

Listen to the chapter

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Reviewed and Edited By

Jonathan Liow

Jonathan conducts healthcare research in the Emergency Department at Tan Tock Seng Hospital. A graduate of the University at Buffalo with a BA in Psychology and Communication, he initially worked on breast cancer research studies at GIS A*STAR. His research interests focus on integrating AI into healthcare and adopting a multifaceted approach to patient care. In his free time, Jonathan enjoys photography, astronomy, and exploring nature as he seeks to understand our place in the universe. He is also passionate about sports, particularly badminton and football.

James Kwan

James Kwan is the Vice Chair of the Finance Committee for IFEM and a Senior Consultant in the Department of Emergency Medicine at Tan Tock Seng Hospital in Singapore. He holds academic appointments at the Lee Kong Chian School of Medicine, Nanyang Technological University, and the Yong Loo Lin School of Medicine, National University of Singapore. Before relocating to Singapore in 2016, James served as the Academic Head of Emergency Medicine and Lead in Assessment at Western Sydney University's School of Medicine in Australia. Passionate about medical education, he has spearheaded curriculum development for undergraduate and postgraduate programs at both national and international levels. His educational interests focus on assessment and entrustable professional activities, while his clinical expertise includes disaster medicine and trauma management.

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.