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Back Pain Emergencies: what you cant afford to miss


Back pain is the fifth leading reason for medical office visits in the US and ... Of the patients who have acute back pain, 90% to 95% have a non life-threatening ... – PowerPoint PPT presentation

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Title: Back Pain Emergencies: what you cant afford to miss

Back Pain Emergencies what you cant afford to
Meghan Rothenberger, MD March, 2007
  • In the US, up to 90 of adults will experience an
    episode of back pain during their lifetime.
  • Back pain is the fifth leading reason for medical
    office visits in the US and the leading cause of
    work-related disability.
  • Of the patients who have acute back pain, 90 to
    95 have a nonlife-threatening condition and
    although up to 85 cannot be given an exact
    diagnosis, nearly all recover within 4 to 6

  • In 5 to 10 of patients, acute back pain is a
    manifestation of more serious pathology such as
  • - Vascular catastrophe (AAA, aortic
  • - Malignancy
  • - Spinal cord compressive syndromes
  • - Infectious disease processes (epidural
    abscess, vertebral

  • osteomyelitis)
  • Although these conditions account for a small
    percentage of causes of back pain, all are
    potentially life threatening and require rapid
  • When the diagnosis is missed or even delayed,
    patients incur substantially higher morbidity and

  • A detailed history is vital.
  • Pay special attention to the these RED FLAGS
  • Gradual onset of back pain
  • Age lt20 years or gt50 years
  • Isolated Thoracic back pain
  • Pain lasting gt 6 weeks
  • History of trauma
  • Fever/chills/night sweats
  • Unintentional weight loss
  • History of intravenous drug use
  • Pain worse with recumbency
  • Pain worse at night
  • Unrelenting pain despite high doses of analgesics
  • History of malignancy
  • History of immunosuppression
  • Recent procedure known to cause bacteremia

Physical Exam
  • Always perform a detailed physical exam, keeping
    in mind that back pain may result from multiple
    organ systems.
  • Dont forget to look at vital signs
  • - hypotension? AAA
  • - hypertension ? aortic dissection
  • - fever ? epidural abscess, vertebral
  • The neurologic exam is critical! Thoroughly
  • - motor function
  • - sensation
  • - deep tendon reflexes
  • - gait
  • - rectal tone
  • - postvoid residual in patients who describe
    urinary retention.

Physical Exam
  • As with the history, there are important Physical
    exam RED FLAGS that should not be overlooked
  • Fever
  • Hypotension
  • Extreme hypertension
  • Pale, ashen appearance
  • Pulsatile abdominal mass
  • Pulse amplitude differentials
  • Spinous process tenderness
  • Focal neurologic signs
  • Acute urinary retention

Work up
  • If Aortic dissection is suspected
  • Emergent imaging required.
  • CXR is only 64 sensitivity and 86 sensitive.
  • Therefore, CT or MRI are needed (CT usually used
    because it is fast).
  • If AAA suspected
  • If patient has hypotension, pain, and pulsatile
    mass CALL SURGERY, check stat labs (including
    type and cross), place central access.
  • If the patient is clinically stable, an urgent CT
    should be obtained to determine size of AAA and
    to rule out rupture.
  • -

Work Up
  • If epidural abscess is suspected
  • Obtain cbc diff, ESR, CRP, blood cultures ( in
    about 60 of these patients).
  • LP NOT recommended.
  • MRI is imaging method of choice because it
    delineates extent of abscess (essential for
    planning surgery), and can differentiate
    infection from cancer.
  • There is a high false negative rate with CT.

MRI scan demonstrating an anterior epidural
Work Up
  • If vertebral osteomyelitis is suspected
  • Check CBC diff, ESR, CRP, blood cultures ( in
    50-70 of patients).
  • Gadolinium-enhanced MRI is the imaging modality
    of choice.
  • If MRI not possible, CT can be used however
    early destructive changes may be missed. CT
    findings may also be nondiagnostic.

MR image demonstrating cervical vertebral
osteomyelitis at C3-4 epidural abscess is also
Work Up
  • If cord compression suspected
    neurosurgical service immediately.
  • MR imaging and myelography are superior to plain
    radiographs, bone scans, and CT for diagnosis.
  • Myelography is often faster, but is invasive and
    has several contraindications (ie coagulopathy).

T2-weighted MRI with soft tissue mass involving
C7, T1, and T2, with collapse of the vertebrae
and cord compression.
Work Up
  • If new diagnosis of malignancy is suspected
    (without evidence of cord compression)
  • Consider these cancers prostate, breast, lung,
    renal cell, non-Hodgkin's lymphoma, and
    plasmacytoma or multiple myeloma (they are the
    most likely to cause lesions in vertebra).
  • Check ESR, CBC, calcium, PSA, SPEP/UPEP
    (depending on suspicion for particular
  • Plain films have poor sensitivity (60 for
    cancer) but may be chosen as initial imaging
    modality given low cost.
  • MRI is the best imaging modality to determine

In Summary
  • Although back pain is extremely common and
    usually self-limited, always think about the
    potentially life threatening conditions that it
    may represent.
  • A detailed history and physical are vital.
  • Dont hesitate to call a surgical consultation
    before obtaining imaging (ie if cord compression
    is suspected).
  • Think about the best imaging procedure for the
    diagnosis being considered obtaining unnecessary
    imaging can be a waste precious time.

  • A. Praemer, S. Furner and D. Rice,
    Musculoskeletal conditions in the United States,
    Proceedings of the American Academy of Orthopedic
    Surgeons, AAOS, Rosemont (IL) (1992), pp. 2333.
  • L.G. Hart, R.A. Deyo and D.C. Cherkin, Physician
    office visits for low back pain frequency,
    clinical evaluation, and treatment patterns from
    a US national survey, Spine 20 (1995), pp. 1119.
  • . Deyo, J. Rainville and D. Kent, What can the
    history and physical examination tell us about
    low back pain, JAMA 286 (1992), pp. 760765.
  • C.B. Higgins, Modern imaging of the acute aortic
    syndrome, Am J Med 116 (2004), p. 134.
  • J.G. Jarvik and R.A. Deyo, Diagnostic evaluation
    of low back pain with emphasis on imaging, Ann
    Intern Med 137 (2002), pp. 586597.
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    Rev Infect Dis 19879265-274. 
  • Curry WT Jr, Hoh BL, Amin-Hanjani S, Eskandar EN.
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