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A N E V I D E N C E - B A S E D A P P ROAC H T O E M E RG E N C Y M E D I C I N E
February 2000
Volume 2, Number 2
Authors
Editor-in-Chief
Stephen A. Colucciello, MD, FACEP,
Director of Clinical Services, Department of Emergency
Medicine, Carolinas Medical
Center, Charlotte, NC; Assistant
Clinical Professor, Department of
Emergency Med-icine, University
of North Carolina at Chapel Hill,
Chapel Hill, NC.
Associate Editor
Andy Jagoda, MD, FACEP, Associate
Professor of Emergency
Medicine, Mount Sinai School of
Medicine, New York, NY.
Editorial Board
Judith C. Brillman, MD, Residency
Director, Associate Professor,
Department of Emergency
Epidemiology
Back pain has an annual incidence of 5% in adults and
affects up to 90% of the general population at some
time in their lives.2 It is second only to upper respiratory illness as a reason for primary care office visits. 3
Patients may come to the ED because the symptoms
either occur or worsen when primary care appointments are unavailable, or because the patient has no
primary care physician. In 1990, the annual cost in the
Concern
Spondylolysis, spondylolisthesis,
discitis, spinal infection, tumor,
developmental disorders
Age greater than 50
Malignancy, fracture, AAA
Trauma
Fracture
Chronic steroid use
Fracture
History of cancer
Malignancy (metastases)
Fever, chills, night sweats
Infection, malignancy
Weight loss
Malignancy, infection
Injection drug use
Infection
Immunocompromise
Infection
Night pain
Malignancy, infection,
ankylosing spondylitis
Unrelenting pain
Malignancy, infection
Incontinence
Epidural compression syndrome
Saddle anesthesia
Epidural compression syndrome
Bilateral neurologic deficit Epidural compression syndrome
Unilateral neurologic
Herniated disc
deficit
Concern
Infection, malignancy
Epidural compression syndrome
Epidural compression syndrome
Epidural compression syndrome,
herniated disc
Epidural compression syndrome,
herniated disc
Herniated disc
Herniated disc
Fracture, infection
Upper motor neuron disorder,
spinal cord compression
February 2000
lumbosacral sprain (LSS) will resolve or have significant improvement in their symptoms within six
weeks.9,10 Pain that lasts greater than six weeks suggests infection or malignancy.11-13 Moreover, those with
symptoms of more than six weeks duration are less
likely to respond to usual conservative management.
Character Of Pain
Discomfort due to LSS is usually well-localized to the
back and upper buttocks. Pain that radiates into the leg
or foot indicates lumbar or sacral nerve root compression and may require further diagnostic studies,
usually on an outpatient basis. Pain radiating to the
groin can occur with both renal colic and AAA. It is
classically taught that the pain of malignancy or
infection does not improve with lying flat and resting,
or is worse at night. Likewise, unrelenting pain despite
adequate treatment and analgesics raises concern for
serious disease.
Vital Signs
Fever in the patient with back pain is concerning
and signals potential infection. However, it is
variably sensitive, ranging from 16% to 83%. The
presence of fever depends upon the location of
infection and the specific pathogen involved.12,14,16,17
Hypotension in the elderly patient with back pain
may presage aortic rupture.
Location Of Pain
While no well-designed studies address this issue, case
series and textbook lore suggest the location of the
pain will narrow the differential diagnosis. Pain
confined to the mid and upper back may be related to
chest pathology, such as thoracic dissection, myocardial ischemia, and pulmonary embolism. Abdominal
disorders such as cholecystitis, pancreatitis, and peptic
ulcer disease are thought to radiate more to the midback. Pelvic pathology produces pain in either the
lower abdomen, lower back, or both.
Associated Symptoms
The Back
Abdominal Examination
Neurologic Examination
An adequate neurologic exam is crucial, as it allows
the emergency physician to identify potentially
catastrophic disease. The exam begins with a sensory
exam, which can adequately be accomplished with
light touch and pinprick. If any deficit is noted, formal
testing involving position sense, sharp/dull, as well as
vibratory sensation may be helpful. An understanding
of the sensory dermatomes (or a copy of the AHCPR
Tests For Low Back Pain on page 13) provides an
important anatomic reference for sensory loss. A
February 2000
Rectal Examination
The rectal examination will evaluate for rectal tone and
sensation, prostatic and rectal masses, and to rule out
peri-rectal abscess as the etiology for the pain. 26 A
rectal exam is not mandatory for every patient who
complains of back pain (although its routine use may
decrease ED visits for bcak pain). However, it should
be performed in all patients with neurologic complaints or deficits. Poor or absent rectal tone in the
presence of saddle anesthesia indicates an epidural
compression syndrome, most commonly a cauda
equina syndrome.
Pelvic Examination
Numerous reports and clinical experience show that
pelvic pathology can produce low back pain. However,
the evidence-based literature is mute on the indications
for pelvic examination in women with low back pain.
February 2000
Non-spinal Conditions
Immediate Threats To
Spinal Cord
Epidural mass effect
Tumor
Hematoma
Abscess
Disc herniation (rarely
causes acute threat in
lumbar area)
Distraction
SLR: Inconsistent findings in sitting vs. supine straight leg
raising
Regional Disturbance
Weakness: Generalized giving way or cog-wheeling
resistance when testing strength in the lower extremities
Sensory: Stocking sensory loss, non-dermatomal
Urgent Threats
Cardiac
Endocarditis
Renal
Pyelonephritis
Infected stone
Renal artery dissection
Abdominal
Perforated ulcer
Vertebral
Unstable fracture
February 2000
Gynecologic
Abruptio placenta
Serious But Not Acutely
Dangerous
Vertebral
Osteomyelitis
Potts Disease (tuberculosis of spine)
Tumor
Stable fracture
Spondylolisthesis
Disc
Herniated Disc
Discitis
Rheumatologic
Ankylosing spondylitis
Abdominal
Pancreatitis
Gynecologic
PID
Less Serious (But May
Represent A Pain
Emergency)
Renal
Ureteral Colic
Gynecologic conditions
Pregnancy
Endometriosis
Ovarian conditions
Dysmenorrhea
Musculoskeletal
Lumbosacral strain
Varicella Zoster
Presentation
Some patients with epidural compression may present
with a dramatic history, such as lower extremity
weakness progressing to paraplegia in a matter of
hours. Others have less sensational complaints of
slowly progressive weakness or numbness. While back
pain is frequent, it may not predominate.
The most important factors to consider are the
bilaterality of the symptoms and the involvement of
more than one spinal level. Lower extremity symptoms
and signs may be associated with bowel or bladder
incontinence and saddle anesthesia. Physical examination
usually reveals bilateral lower extremity weakness,
hyporeflexia, and abnormal sensation. Often, there is no
specific nerve root distribution as multiple spinal levels
are involved, although one should attempt to determine a
spinal level. Urinary incontinence results from bladder
spasms secondary to associated urinary retention.
Urinary retention is approximately 90% sensitive for cauda
equina syndrome, while decreased anal sphincter tone
occurs in 60-80% of cases.21 Urinary retention or a
complaint of urinary incontinence is easily evaluated by
obtaining a post-void residual through catheterization.
Any residual volume greater than 50-100 mL is cause for
concern. Alternatively, ED ultrasonography may determine post-void residual in a non-invasive manner.
Etiologies
In the younger adult population, epidural compression
usually results from a cauda equina syndrome due to a
large central disc herniation. However, other etiologies to
consider in all age groups include primary or metastatic
Management
When an emergency physician suspects an epidural
Etiology/Findings
Ligamentous and muscular strain
History of overuse or trauma
Worse with activity, better with rest
Tenderness with lumbosacral palpation
Red Flags
None
Sciatica
Yes
(Neurologic complaints)
(Neurologic deficits)
Yes
(Neurologic complaints)
(Neurologic deficits)
Yes
(Neurologic complaints)
(Neurologic deficits)
Yes
(Fever, night sweats)
(Weight loss)
(Unrelenting pain)
February 2000
Sciatica
Prognosis
The prognosis of epidural compression syndrome
depends upon the patients neurological status at the
time of intervention. Specifically, for those patients
with epidural compression due to malignancy, those
who are ambulatory generally remain so. Of patients
who are paraplegic at intervention, approximately 10%
regain ambulation. 30,31
Spinal Infections
Infection is an uncommon cause of back pain that
generally occurs in immunocompromised patients
(diabetics, injection drug users [IDUs], transplant
patients, and cancer patients). These patients typically
have prolonged symptoms, and in more than half of
those with osteomyelitis, the pain has been present for
three or more months.16,17,22,32
Pain is nearly a universal complaint in spinal
infections. The pain is often insidious, and becomes
unrelenting and nocturnal. The most common spinal
infections include vertebral osteomyelitis and
epidural abscess. Staphylococcus aureus is the
predominant pathogen, although S. epidermidis,
Streptococci, and even urinary pathogens such as
E. coli or Proteus occur.12,13,15-17
The physical exam can be misleading in patients
with spinal infections. In vertebral osteomyelitis, fever
occurs in only half of patients; epidural abscess is
much more likely to produce fever.12,15-17,33 Most
patients will have vertebral body percussion tenderness, although this finding is nonspecific.
Lab testing can also be deceptive. The white blood
cell (WBC) count is elevated in fewer than 50% of
patients with spinal infection. 12,13,15-17,34 However, the
erythrocyte sedimentation rate (ESR) is a sensitive but
nonspecific screening test, elevated in greater than 95%
of patients with a normal immune system and 90% of
those with immune suppression.12,13,16,17,22
The emergency physician should order diagnostic
imaging when they suspect spinal infection. Plain films
may be useful, but a spinal MRI (the gold standard) or
CT is more sensitive and specific than radiographs.
This is especially true early in the disease process, as it
may take up to eight weeks before lytic changes
become evident on x-ray.17,32
The prognosis for spinal infection is fair, with
mortality rates ranging from less than 5% to greater
than 25%. 12,15-17,32 The outcome depends upon the nature
of the infection (osteomyelitis vs epidural abscess), the
patients immune system status, and general health.
February 2000
Continued on page 15
Age >18 years non-pregnant acute (<4 weeks duration) low back pain and/or back-related leg symptoms, not suspected to be
renal colic?
Focused HPI:
Location of symptoms: Back, leg, both
Duration
Functional limitations
Mechanism of onset: Spontaneous or specific (trauma)
Character or description of pain: Mechanical, radicular, non-specific, increased by rest, nocturnal pain
Previous treatment and response
Neurologic history: Distribution, bowel and bladder symptoms, sexual dysfunction, weakness, numbness (including saddle),
signs/symptoms of cauda equina syndrome
Fever
Unexplained weight loss
History of malignancy
History of intravenous drug use
Mental health/psychiatric/rehabilitation problems
Prior back surgery
Yes
Plain x-ray
(Class IIa)
Evidence of
fracture or
serious disease?
Yes
No
No
Go to Evidence of non-spinal
medical problems causing
referred back complaints? path
on next page
The evidenc e for recommenda tions is graded using the following scale. For complete definitions, see back page. Class I: Definitely recommended.
Definitive, excellent evidence provides support. Class II a: Acceptable and useful. Very good evidence provides support. Class II b: Acceptable and useful.
Fair-to-good evidence provides support. Class III: Not acceptable, not useful, may be harmful. Indeterminate: Continuing area of research.
This clinical pathway is intended to supplement, rather than substitute, professional judgment and may be changed depending upon a
patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2000 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants permission to reproduce this
Emergency Medicine Practice tool for institutional use.
February 2000
Yes
Yes
No
Yes
Evidence of
fracture or
serious disease?
Yes
Special thanks to Dr. Andrew Asimos for this adaptation from the
AHCPR guidelines.
Go to page 10
Neurologic deficit:
Motor and/or reflex changes
Objective sensory loss
Yes
Go to page 10
No
Evidence of non-spinal
medical problems causing
referred back complaints?
No
No
Yes
No
February 2000
Evidence of
fracture or
serious disease?
No
No
Yes
No
Epidur al compression?
Saddle anesthesia
Urinary retention
Incontinence
Neurological deficit
Acute
lumbosacral strain
(Class I)
Yes
Yes
Dexamethasone (Class I)
Emergent MRI (Class I)
Consult (Class I)
No
Yes
Yes
Consistent with
infection?
No
No
Admit/consult
(Class I)
Consider antibiotics
in ED (Class IIb)
Yes
Tumor?
Age > 50
Night pain, unrelenting
pain
Weight loss
Pain > 6 weeks
Fever
CT or MRI (Class I)
Plain radiography (Class IIb)
CBC, ESR, UA C&S (Class I)
Blood culture x 2 (Class IIa)
Infection?
Fever, night sweats
Night pain, unrelenting
pain
Injection drug user
Immunocompromised
Pain > 6 weeks
Consistent with
tumor?
Specialty consultation
(Class I)
No
Yes
No
The evidenc e for recommenda tions is graded using the following scale. For complete definitions, see back page. Class I: Definitely recommended.
Definitive, excellent evidence provides support. Class II a: Acceptable and useful. Very good evidence provides support. Class II b: Acceptable and useful.
Fair-to-good evidence provides support. Class III: Not acceptable, not useful, may be harmful. Indeterminate: Continuing area of research.
This clinical pathway is intended to supplement, rather than substitute, professional judgment and may be changed depending upon a
patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2000 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants permission to reproduce this
Emergency Medicine Practice tool for institutional use.
10
February 2000
Sciatica?
No
Yes
Normal?
No
Reevaluate (Indeterminate)
Yes
Normal?
Yes
No
No
Yes
Fracture?
History of trauma
Age > 50
Osteoporosis
Consistent with
spondylolysis or
spondylolisthesis?
Yes
No
Reevaluate (Indeterminate)
The evidenc e for recommenda tions is graded using the following scale. For complete definitions, see back page. Class I: Definitely recommended.
Definitive, excellent evidence provides support. Class II a: Acceptable and useful. Very good evidence provides support. Class II b: Acceptable and useful.
Fair-to-good evidence provides support. Class III: Not acceptable, not useful, may be harmful. Indeterminate: Continuing area of research.
This clinical pathway is intended to supplement, rather than substitute, professional judgment and may be changed depending upon a
patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2000 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants permission to reproduce this
Emergency Medicine Practice tool for institutional use.
February 2000
11
Yes
Group I:
New or progressive
neurologic symptoms?
Yes
No
Yes
No
X-rays consistent
with mets/tumor?
Yes
Dexamethasone
(Class I)
MRI < 24 hours
(Class I)
No
X-rays consistent
with mets/tumor?
Yes
Consult (Class I)
No
The evidenc e for recommenda tions is graded using the following scale. For complete definitions, see back page. Class I: Definitely recommended.
Definitive, excellent evidence provides support. Class II a: Acceptable and useful. Very good evidence provides support. Class II b: Acceptable and useful.
Fair-to-good evidence provides support. Class III: Not acceptable, not useful, may be harmful. Indeterminate: Continuing area of research.
This clinical pathway is intended to supplement, rather than substitute, professional judgment and may be changed depending upon a
patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2000 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants permission to reproduce this
Emergency Medicine Practice tool for institutional use.
12
February 2000
L4
L5
S1
Pain
Great toe
Heel
Numbness
3.With the other hand cupped under the heel, slowly raise
the straight limb. Tell the patient, If this bothers you, let
me know, and I will stop.
4.Monitor for any movement of the pelvis before complaints are elicited. True sciatic tension should elicit
complaints before the hamstrings are stretched enough
to move the pelvis.
Screening
exam
Reflexes
Extension of
quadriceps
Dorsiflexion
of great toe
and foot
Squat
and rise
Heel
walking
Knee jerk
diminished
None
reliable
Plantar flexion
of great toe
and foot
Walking
on toes
6.While holding
the leg at the
limit of straight
leg raising,
dorsiflex the
ankle. Note
whether this
aggravates the
pain. Internal
rotation of the
limb can also increase the tension on the sciatic nerve
roots.
Ankle jerk
diminished
Adapted from: Bigos S, Bowyer O, Braen, et al. Acute low back problems in adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642.
Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. December 1994.
Agency for Health Care Administration, State of Florida, in Consultation with the Medical/Surgical Neuro-Musculo-Skeletal Guideline Committee and
its Neurosurgical Surgery Subcommitee: Universe of Florida Patients with Low Back Pain or Injury. Medical Practice Guidelines for Practitioners
Licensed Under Chapter 458 (Medicine) or Chapter 459 (Osteopathy), Florida Statutes, Florida Health Care Insurance Reform Act of 1993, Section
4108.02; Florida Workers Compensation Reform Act of 1993, Section 440.13(15). Endorsed October 6, 1995; amended February 2, 1996.
February 2000
13
Recommend:
Basic history (B).
History of cancer/infection (B).
Signs/symptoms of cauda equina syndrome (C).
History of significant trauma (C).
Psychosocial history (C).
Straight leg raising test (B).
Focused neurological exam (B).
Recommend:
Manipulation of low back during first month of symptoms (B).
Option:
Manipulations for patients with radiculopathy (C).
Manipulation for patients with symptoms >1 month (C).
Self-application of heat or cold to low back (C).
Shoe insoles (C).
Corset for prevention in occupational setting (C).
Option:
Pain drawing and visual analog scale (D).
Recommend against:
Manipulation for patients with undiagnosed neurologic
deficits (D).
Prolonged course of manipulation (D).
Traction (B).
TENS (C).
Biofeedback (C).
Shoe lifts (D).
Corset for treatment (D).
Option:
Epidural steroid injections for radicular pain to avoid surgery (C).
Recommend:
CT or MRI when cauda equina, tumor, infection, or fracture strongly
suspected (C).
MRI test of choice for patients with prior back surgery (D).
Assure quality criteria for imaging tests (B).
Recommend against:
Epidural injections for back pain without radiculopathy (D).
Trigger point injections (C).
Ligamentous injections (C).
Facet joint injections (C).
Needle acupuncture (D).
Option:
Myelography or CT-myelography for preoperative planning (D).
Recommend against:
Use of imaging test before one month in absence of red flags (B).
Discography or CT-discography (C).
Option:
Bed rest of 2-4 days for severe radiculopathy (D).
Recommend against:
Bed rest >4 days (B).
Recommend:
Acetaminophen (C).
NSAIDs (B).
Option:
Muscle relaxants (C).
Opioids, short course (C).
Recommend against:
Opioids used >2 wks (C).
Phenylbutazone (C).
Oral steroids (C).
Colchicine (B).
Antidepressants (C).
Recommend against:
Back-specific exercise machines (D).
Therapeutic stretching of back muscles (D).
Adapted from: Bigos S, Bowyer O, Braen G. et al. Acute Low Back Problems in Adults. Clinical Practice Guideline, Quick Reference Guide Number 14.
Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, AHCPR Pub.
No 95-0643. December 1994.
14
February 2000
Diagnostic Studies
Laboratory
Most patients with low back pain do not need laboratory testing in the ED. In selected patients, a few tests
may be helpful. These include a complete blood count
(CBC), a urinalysis (UA), and an erythrocyte sedimentation rate (ESR). These studies are indicated when the
patient has red flags for infection or tumor, or when a
child presents with atraumatic back pain.
Blood Tests
The ESR is especially sensitive to spinal
infection.12,13,15-17,22,34,39 In addition to non-spinal
infections (such as endocarditis), the ESR may also
be elevated in the setting of neoplasm and rheumatologic disease, such as ankylosing spondylitis.11,40
While the CBC remains a reflex response to fever
(despite the best efforts of Emergency Medicine Practice),
it falls short in its performance in patients with spinal
infections. In most cases, it is falsely normal despite
significant disease.
Radiographic Studies
Plain Radiography
Plain spinal radiographs are indicated whenever there is
history of significant trauma, suspicion of fracture,
infection, tumor, or neurologic deficit. Older patients and
those on chronic steroids may require x-rays after even
minor trauma, especially if they demonstrate percussion
tenderness of the vertebrae. Plain films are limited in
their ability to detect infection, tumor, or herniated disc.
It is unnecessary to obtain plain films in patients with
only back pain and no red flags. Because symptoms will
resolve in approximately 90% of these patients within 4
Urinalysis
The urinalysis may be useful in a variety of patients
with back pain, both acute and chronic. In the patient
with acute severe pain in the back or flank, a urinalysis
is routinethe assumption being that the presence or
absence of hematuria should direct evaluation of
possible renal colic. However, recent data tends to
February 2000
15
spinal infection, tumor, herniated disc, spinal hematoma, and acute neurological deterioration, because
it clearly delineates spinal cord, canal, and disc
anatomy.12,32,34,46,47 Furthermore, MRI does not use
ionizing radiation. For this reason, it is the imaging
study of choice in pregnant women.47
Limitations Of MRIs
Limitations include availability, cost, time, claustrophobia, contraindications, and over-sensitivity. MRI is
not available emergently, or at all, in many smaller
hospitals. The average charge for an MRI with contrast
of the lumbosacral spine is approximately $1,600,
whereas a non-contrast CT scan of the same area costs
$650 (plus a myelography fee, if used). Also, MRI
requires a significant amount of time depending on the
number of spinal segments scanned. This may be
extremely uncomfortable for the claustrophobic patient
and frankly dangerous for the patient who is deteriorating rapidly. MRI is contraindicated in individuals
with pacemakers, intracardiac wires, some intracranial
aneurysm clips, and some types of heart valves.
Finally, MRI is overly sensitive when used indiscriminately. In one study, in patients with no history or
symptoms of back pain, MRI demonstrated disc
herniation or bulging in 22% of patients younger than
60 years old and in 36% of those over age 60.48 Most
authorities do not consider isolated foot drop secondary to a presumed herniated disc to be an indication
for an acute MRI, since few surgeons would acutely
operate on such a patient.
MRI
Any patient with signs or symptoms suggestive of
epidural compression warrants an emergent MRI. The
MRI may initially be limited to the lumbosacral spine
in patients with suspected cauda equina syndrome
secondary to disc herniation, especially if back pain is
localized to the lower lumbar spine. However, the
entire spine (cervical, thoracic, lumbar, and sacral)
should be evaluated in patients with suspected spinal
cord compression for two reasons. First, there is the
risk of localizing the physical findings to the wrong
spinal level and potentially missing a more proximal
lesion on the MRI. 45,46 Second, there is a 10% chance of
asymptomatic distant metastases in metastatic cord
compression, and their discovery may alter the
therapeutic plan.30 In addition to diagnosing epidural
compressive lesions, MRI is the gold standard test for
CT Scan
The primary indication for CT scanning in the setting
of low back pain is fracture evaluation, since CT is
superior to MRI in evaluating bony architecture.
However, when used in conjunction with myelography,
CT scanning is as effective as MRI in diagnosing
16
February 2000
Spinal Infection
Attempt to identify the causative organism in patients
with red flags for infection. Two sets of blood cultures
as well as a urine culture should be collected before
starting antibiotics. 12,16,17,34 It is appropriate to discuss
the timing of antibiotics with the consultant. Some
consultants prefer emergent or urgent surgical investigation before antibiotics. Some patients benefit from
biopsy and culture of the suspected site of infection to
determine the responsible organism. Initiation of
antibiotics before biopsy may yield a false-negative
culture and force prolonged empiric treatment.
All patients with suspected spinal infection require
hospital admission for intravenous antibiotics. When
empiric therapy is chosen, direct it toward the most
common organism, S. aureus. 12,15,17,22,33 In patients with
suspected spinal infection, obtain an MRI within 24
hours to confirm the clinical suspicion.
Treatment
The treatment of low back pain obviously depends on
the cause. Pain management is appropriate for nearly
every patient, with the possible exception of the
hypotensive victim of a ruptured AAA.
February 2000
17
ally used to treat low back pain include acetaminophen, non-steroidal anti-inflammatory agents
(NSAIDs), muscle relaxants, and opioid analgesics.
NSAIDs
NSAIDs have long been the mainstay of pharmacotherapy. Although randomized, placebo-controlled
studies of back pain are few, it is likely that most drugs
of this class are equally effective.50 The most common
side effects include gastrointestinal irritation and
deterioration of renal function. Because of these side
effects, one may consider a trial of acetaminophen
alone or in combination with an opioid or muscle
relaxant in those at risk for NSAID complications.
This at-risk population includes the elderly, those
with prior GI bleeds, and patients with impaired
renal function.
Other Modalities
Numerous modalities, including spinal traction,
massage, diathermy, ultrasound, biofeedback, transcutaneous electrical nerve stimulation (TENS), acupuncture, and trigger point injections have been used to
treat acute low back symptoms. These therapies have
no proven benefit in alleviating pain.9 One may
educate the patient on the use of heat or cold for
temporary symptom relief,9 but there are no good trials
to promote one modality over another.
Acetaminophen
Not only does acetaminophen have fewer side effects
than the NSAIDs, but it is less expensive. Acetaminophen has similar therapeutic effects as compared to
NSAIDs for other musculoskeletal conditions, such as
osteoarthritis.51 If one suggests acetaminophen alone,
consider a back-up regimen in case the acetaminophen
is insufficient. The back-up prescription could
prevent a repeat visit to the ED or the primary
physicians office.
Treatment Of Sciatica
The treatment of sciatica is similar to that of acute
lumbosacral strain, but there are some exceptions.
About 80% of patients with a herniated disc improve
with nonsurgical therapy, with only 5-10% ultimately
requiring surgery.2,24,35 Conservative management
with acetaminophen, NSAIDs, opioids, and/or
muscle relaxants is the best ED approach. As with
lumbosacral strain, the patient with sciatica should
resume routine activity as tolerated by pain. Recent
studies show that early mobilization is more effective
than bedrest. 56 Although proponents of manipulative
therapy do not consider sciatica as a contraindication
to manipulation, manipulation may cause or worsen
neurological deficits.2
While systemic corticosteroid therapy has no
proven value for either sciatica or LSS,50 epidural
steroid injections may be indicated in some patients
with sciatica. While studies give conflicting
results, 12,57-59 one meta-analysis demonstrated a marginal (10-15%) reduction in pain following epidural
steroid injection vs. placebo in patients with sciatica.50
Opioids
If the pain is more severe, give narcotic analgesics in
the ED and prescribe them for home use. The duration
is best limited to 1-2 weeks due to the risk of sedation
and constipation. Caution the patient not to combine
acetaminophen with any acetaminophen-narcotic
combination medications.
Muscle relaxants such as diazepam, carisoprodol,
and methocarbamol are also effective in treating acute
low back pain. Several studies have shown them to be
better than placebo in the treatment of low back pain. 50
However, they are no more effective than NSAIDs in
low back pain, and they have no synergistic effects
when used in combination with NSAIDs.50 They are an
alternative therapy, especially in the patient at high
risk of side effects from NSAIDs.
Bed Rest
Until the mid-1980s, patients with acute lumbosacral
strain were placed on seven days of strict bed rest.
Subsequent research demonstrated that two days of bed
rest were as effective as seven days.52 Even more recent
data indicates that even two days of bed rest may be
excessive. Studies indicate that patients who resume
normal activities as tolerated by pain recover more
rapidly than those placed at bed rest.53 Back mobilizing
exercises do not appear valuable in the acute setting.
Special Circumstances
Children and patients with a history of cancer are
the primary subsets of patients in whom serious
etiologies for back pain are most likely. The emergency
physician should use extreme caution when evaluating
these patients.
Spinal Manipulation
One especially controversial treatment option is
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February 2000
3. She only fell out of a chair. I dont x-ray every little old
lady who hurts herself when she falls.
This case was eventually dropped, since one of the
plaintiffs experts admitted that the film would not have led
to a major change in management. However, the
compression fracture caused her months of pain. In
addition, she was angry about the little old lady wisecrack.
4. I thought he was drug-seeking. It was his third visit to
the ED in less than a week complaining of pain.
People with serious disease have serious pain. Unremitting
pain despite standard management is worrisome for
tumor or infection. Look for other red flags in the history
and physical.
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19
Summary
Back Pain In The Patient With A History Of Cancer
No need to put the chart back in the rack! The emergency physician should view back pain as an important and manageable condition. The emergency
physician may provide a rapid yet thorough evaluation
by focusing on the red flags of the history and physical
exam. These red flags will drive further diagnostic
testing and eliminate immediate threats to life and to
the cord. Conservative treatment is the best approach
to treating back pain, as symptoms resolve within 4-6
weeks in the majority of patients. Be cautious in highrisk patients, such as the elderly, children, the
immunocompromised, and those with a history of
cancer. Adherence to these principles (and a copy of
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February 2000
informative references cited in the paper, as determined by the authors, will be noted by an asterisk (*)
next to the number of the reference.
1.
References
*2.
3.
4.
5.
Tool 1. Sample Discharge Instructions For Patients With Low Back Pain.
Copyright 2000 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants permission to reproduce this
Emergency Medicine Practice tool for institutional use.
Activity:
_____ Activity as tolerated (stop doing something if it hurts)
_____ No lifting more than ______ lbs.
_____ Other: _________________________________________________________________________________
Sleeping:
Rest on a firm mattress. If you get pain down your legs, sleeping on your side with your legs bent at the hips and
knees will help.
If you sleep on your back, putting a fat pillow under your knees may help.
Come back to the Emergency Department immediately if you develop any of the following:
Leaking urine or unable to urinate
New numbness or weakness in your legs
Inability to walk
Inibility to control your bowels
High fever
Medication:
_____ You have been given a medication that may make you sleepy or drowsy.
Do not drive yourself home from the Emergency Department
Do not drive a car or operate machinery within 12 hours of taking this medicine
Do not drink alcohol while taking this medicine
Other Medicine:
_____ Take over-the-counter ibuprofen:
_____tabs every ______ hours for _______days
_____ Other: _________________________________________________________________________________
Follow-Up:
_____ See your doctor in ____ days
_____ Call ___________ for an appointment within ________days
Other Instructions:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Remember that the emergency department is open 24 hours a day, every day, and we are always glad to
see you.
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28.
29.
30.
*31.
32.
33.
34.
35.
36.
37.
*38.
39.
40.
41.
42.
43.
44.
45.
*46.
47.
48.
49.
*50.
51.
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February 2000
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
February 2000
23
Class III:
Unacceptable
Not useful clinically
May be harmful
Level of Evidence:
No positive high-level data
Some studies suggest or
confirm harm
Indeterminate
Continuing area of research
No recommendations until
further research
Level of Evidence:
Evidence not available
Higher studies in progress
Results inconsistent,
contradictory
Results not compelling
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February 2000