31 - Back Pain

Abstract

While most cases of back pain are non-specific and improve without laboratory evaluation or imaging, the aim of the emergency department (ED) assessment is to identify those serious and emergent pathologies that require urgent treatment. A thorough history and physical exam should be performed with the goal of uncovering high-risk features predisposing the patient to an emergent or life-threatening etiology. The presence of multiple key clinical findings may increase the probability of disease and is often an indication for further investigation. However, blindly allowing the presence or absence of these individual findings to guide diagnostic treatment will lead to potentially unnecessary, misleading, and costly investigations in most patients. Imaging and laboratory studies are indicated only when there is evidence of neurologic deficit or multiple key clinical findings suggesting a dangerous or systemic pathologic cause. Patients who have low back pain emergencies are generally classified into five groups: (1) back pain with neurologic findings in a patient with malignancy history; (2) back pain and symptoms of epidural compression syndrome; (3) back pain with symptoms suggesting an infectious cause; (4) back pain with gross muscle weakness or paralysis; and (5) back pain with severe or progressive neurologic deficits. When a critical diagnosis is strongly suspected, magnetic resonance imaging and spine surgery consultation should be undertaken urgently. Adherence to published guidelines will decrease improper laboratory studies and imaging, thereby lowering costs, improving ED throughout as well as patient care. Conservative therapies are recommended for most patients with non-emergent pain given the high likelihood for recovery.