Back Pain

by Funda Karbek Akarca

Case Presentation

A 45-year-old age male presented to the emergency department with severe back pain after lifting a heavy object. He described the pain radiated to the right leg. He had difficulty with walking. His medical history revealed no additional diseases except for occasional back pain. The vital signs were normal. The physical examination showed palpable peripheral pulses, no motor or sensory deficit, no drop foot or murmur in the abdomen. Straight leg raising test is positive at 45 degrees. Palpation of the vertebrae revealed no tenderness on spinous processes but paravertebral muscles spasm. The patient’s pain decreased after resting in the supine position, muscle relaxants, and analgesics. The patient was discharged with a recommendation of neurosurgery visit in ten days.

Critical Bedside Actions and General Approach

Back pain is a common problem and affects up to 90% of the general population at some point in their lives. It is the fifth leading cause and accounts for 2% to 3% of emergency department visits. Although most back pain is due to a benign and self-limiting reason, a minority of patients may face a risk of permanent neurological damage or death.
Acute, non-traumatic low back pain can be divided into three groups: musculoskeletal causes with no neurologic deficits, musculoskeletal causes with neurologic deficits and other causes that can present with back pain.

• Check vital signs; especially fever
• Learn the history of current illness; pain duration, how the pain started and spread.
• Take medical history; disc herniation history, recent spinal anesthesia or surgery, corticosteroid or anticoagulant use, cancer
• Make an orderly and thorough physical examination
• Order necessary imaging and labs
• Assess the risks and consider the potentially life-threatening or debilitating diagnoses.

Differential Diagnoses

Spinal origin

• Musculoligamentous
• Discopathy
• Fracture
• Spondylolisthesis
• Vertebral osteomyelitis
• Spinal epidural abscess
• Spinal epidural hematoma
• Neoplasm/metastatic disease

Nonspinal causes

• Abdominal aortic aneurysm
• Aortic dissection
• Upper Urinary Tract Infection, renal infarction, renal colic
• Abdominal infection (cholecystitis, cholangitis, pancreatitis, retroperitoneal abscess)
• Abdominal neoplasm

History and Physical Examination Hints

• In many patients, a thorough history and physical examination are essential and sufficient for diagnosis. The tips indicating severe pathologies should be investigated (red flags are shown in Table 1). Additional questions are whether the patient has a similar pain before, has any prior diagnosis related to this complaint or receive any treatment.

Red Flags In Back Pain

History	Physical examination
Pain duration more than 6 weeks	Fever
Age;child or elderly	Major motor weakness esp. bilaterally
Fever, malaise, weight loss	Saddle anesthesia
IV drug use	Perianal sensory loss
Corticostreoid use	Urinary retansion
Cancer history (especially bone metastasis)	Anal sphincter laxity
Trauma esp. in elderly	Fecal incontinance
Recent instrumentation or spinal anesthesia

provided by author

• The typical back pain from muscles or ligaments is generally easily localizable, increases with movement and decreases after rest. The pain rarely radiates, but when it does, it radiates to the pelvis. It the pain radiates below the knee, it may point to L3 nerve root radiculopathy. However, about %90 of the disc herniations relate to L4-5, L5-S1 regions (Figure 1. The location of pain and nerve root innervation).

• The duration of pain is important. The musculoskeletal pain generally limits itself in 4-6 weeks. Consider malignancy if the pain lasts longer.
• The patients under 18 and over 50 years old are under risk for non-musculoskeletal pathologies.
• The systemic symptoms are another tip for non-musculoskeletal pain. Fever, tremor, night sweating, anorexia, unexplained weight loss are significant for infection and malignancy. Immunocompromised patients (diabetic, the corticosteroid use, IV drug use) may not develop a healthy inflammatory response and accordingly the systemic symptoms; therefore, they may require further investigations. Consider spine infections in IV drug users.
• The prior cancer diagnosis should make the physician consider spine metastases. Especially breast, lung, thyroid, kidney, prostate cancers and lymphoma tend to metastasize to the spine.
• The physical examination aims to detect the risk factors and neurologic deficits. Check the vital symptoms at the beginning. Fever may point to spinal infections, but its sensitivity is low.
• Lying flat will decrease the musculoskeletal pain. If the pain increases with lying, consider nephrolithiasis, spine infection, abdominal aortic aneurysm. Check all patients for abdominal tenderness, a palpable pulsatile mass, and murmur.
• Assess vertebral tenderness; erythema, increased heat, purulent lesion over the adjacent skin. Evaluate each vertebral spinous processes individually.
• Apply straight leg raise test (Lasegue’s test) by elevating each leg slowly while the patient in supine position. Increased pain or reproduced sciatic symptoms during test means positive (Figure 2. Straight leg raise test).

• If the pain occurs at 30-35 degree angle, it is considered significantly positive. The radicular pain worsens with ankle dorsiflexion and improves with plantar flexion. Straight leg raise test highly sensitive but not specific. Contralateral (opposite or well-leg) straight leg raise is highly specific but poorly sensitive for L4-5 or L5-S1 radiculopathy. In other words, a negative contralateral straight leg raise is useful to exclude disk protrusion (see videos the tests below).

• Evaluate ankle and the first toe’s dorsiflexion and plantar flexion for L5-S1 nerve roots. Examine patella and ankle deep tendon reflexes. Evaluate bilateral dermatomes and check for saddle anesthesia. Test the sensation of light touch along dermatomes from L1 to S1. Standard dermatomal charts can be helpful, but there is variability between individuals, and this test is highly subjective. In the upper lumbar roots, there is often a significant overlap. The L4, L5 and S1 nerve roots are the most discrete levels for testing. Additionally, these are the most often affected lumbar discs.
• The rectal examination is not routinely indicated. However, in case of bladder or bowel incontinence, it is mandatory. Decreased rectal tone and the sensorial defect may make the physician consider epidural compression syndrome.

Emergency Diagnostic Tests and Interpretation

• History and physical examination are essential. Laboratory testing is generally not useful.
• Elevated white blood cell (WBC) may point to the infectious diseases. However, WBC is high only in the two-thirds of the patients with a spinal epidural abscess.
• Inflammatory markers (Eritrosit sedimentation rate or C-reactive protein) are highly sensitive but not specific for epidural abscess or cancer.
• Lumbosacral anterior-posterior and lateral X-rays are indicated in case of suspected fractures, especially in patients over 50 years old.

• Bedside ultrasound should be performed if the patient has urinary retention or suspected abdominal aortic aneurysm dissection.
• The computed tomography can be useful in fractures or facet joint pathologies.

• Magnetic Resonance Imaging (MRI) visualizes abscess, metastatic lesions, and hematoma (Image 7). Additionally, patients with neurological deficits requiring urgent surgery may necessitate MRI.

Emergency Treatment Options

Initial Stabilization

Structured management is essential in the emergency department. Stabilization is a priority. A critical abnormality in the vital signs and clinical may lead to the early intervention in the life-threatening diseases and permanent neurological damage is at stake. After stabilization, pain control should be provided.

Medications

• Pain is the main symptom. Non-steroidal anti-inflammatory drugs (NSAIDs) are considered as first-line therapy for acute back pain. Ibuprofen has less adverse effects and toxicity.
• Acetaminophen may be another choice.
• Opioids analgesics should not be administered more 1-2 weeks.
• The muscle relaxants are another treatment choice.
• The use of steroids is not recommended due to lack of evidence.
• The patients should return to their daily activities after a few days of bed rest.

Pediatric, Geriatric, Pregnant Patient, and Other Considerations

Pediatric considerations

In the pediatric age group, back pain is unusual. Consider the infectious causes. Ibuprofen is the preferred analgesic in this population.
For children: Ibuprofen; Infants and Children <50 kg: Limited data available in infants <6 months: 4 to 10 mg/kg/dose every 6 to 8 hours; maximum single dose: 400 mg; maximum daily dose: 40 mg/kg/day. Children ≥12 years: Refer to adult dosing.

Elderly considerations

Consider fractures in elderly patients with relatively minimal trauma. Additionally, consider non-musculoskeletal causes of back pain, such as abdominal pathologies, aortic aneurysm or dissection.

Pregnant considerations

Back pain is frequent in later pregnancy. The neurological deficit is infrequent. Pain control via analgesics and back strengthening exercises are recommended. Paracetamol is considered safe in pregnancy and should remain the first-line treatment for pain and fever. General Dosing Guidelines: 325 to 650 mg every 4 to 6 hours or 1000 mg every 6 to 8 hours.

Disposition Decisions

Admission Criteria

• Patients with uncontrolled pains
• Patients with progressive neurological deficit
• Patients with symptoms of cauda equina syndrome
• Patients with infectious, vascular or malignant pathologies

Discharge Criteria

Patients with musculoskeletal pain without neurological deficits may be discharged after pain control

Referral

Patients should be referred to neurosurgical or orthopedic surgery departments.

Pearls and Pitfalls

• Musculoskeletal causes with no neurologic deficits include degenerative spine disease, muscular or ligamentous injury and mostly acute disc pathologies. These patients have normal neurologic examination but have severe pain.
• If the patient has positive neurologic findings during the examination, consider sciatica with radiculopathy and the severe other diagnoses.
• Don’t forget that new neurologic physical findings suggest severe disease and serious diseases have normal neurologic examination findings. Emergency physicians must think broadly and consider nonspinal causes of back pain like an aortic aneurysm.

References and Further Reading

• Pitts SR, Niska RW, Xu J, et al. National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. Natl Health Stat Rep. 2008:1-38.
• Friedman BW, Chilstrom M, Bijur PE, et al. Diagnostic testing and treatment of low back pain in United States emergency departments: a national perspective. Spine. 2010;35:E1406-1411.
• Borczuk P, Burns BD, Henry GL, et al. An evidence-based approach to the evaluation and treatment of low back pain ın the emergency department. Emergency Medicine Practise. 2013;15(7)
• Della-Giustina D. Evaluation and treatment of acute back pain in the emergency department. Emerg Med Clin North Am. 2015 May;33(2):311-26.
• Frohna WJ. Back pain. In: Judith E. Tintinalli, J. Stephan Stapczynski, O. John Ma, David M. Cline, Rita K. Cydulka, Garth D. Meckler, The American College of Emergency Physicians. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide 7th Edition. New York, NY: McGraw-Hill; 2011.
• Lin M. Musculoskeletal Back Pain In: Marx J, Hockberger R, Walls R, editors. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 8th Edition. Philadelphia, PA: Elsevier. 2013:591-603
• Downie A, Williams CM, Henschke N, et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ. 2013;347:f7095.
• Edlow JA. Managing Nontraumatic Acute Back Pain. Ann Emerg Med. 2015 Aug;66(2):148-53.
• https://www.youtube.com/watch?v=4ik29RwqA3s
• https://www.youtube.com/watch?v=zfWKcTixM6E
• Willis J, Legome E. Back pain. In: Jeffrey J. Schaider, Roger M. Barkin, Stephen R. Hayden, Richard E. Wolfe, Adam Z. Barkin, Philip Shayne, Peter Rosen, editors. Rosen & Barkin’s 5-Minute Emergency Medicine Consult 5th Edition. Philadelphia, USA Wolters Kluwer Health; 2015:563-571.
• Tayal VS, Graf CD, Gibbs MA. Prospective study of accuracy and outcome of emergency ultrasound for abdominal aortic aneurysm over two years. Acad Emerg Med. 2003;10(867-71).
• Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.
• Cantrill SV, Brown MD, Carlisle RJ, et al. Clinical policy: critical issues in the prescribing of opioids for adult patients in the emergency department. Ann Emerg Med. 2012;60(4):499- 525. (Clinical policy)
• Balakrishnamoorthy R, Horgan I, Perez S, et al. Does a single dose of intravenous dexamethasone reduce Symptoms in Emergency Department Patients With Low Back Pain and Radiculopathy (SEBRA)? a double-blind randomised controlled trial. Emerg Med J. 2015;32: 525-530.
• Dahm KT, Brurberg KG, Jamtvedt G, et al. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2010 Jun 16;(6):CD007612. (Cochrane systematic review)