NB. these guidelines may apply to primary care cohorts but may NOT apply to ED cohorts where there are higher pre-test probabilities of serious pathology!
back pain can be a very deceptive presentation, all too easily put down to muscle strain or disc prolapse while missing potentially time critical diagnoses.
watch for red flags in the presentation and specifically search for and exclude the main differentials.
patients with chronic back pain can be difficult to manage in the ED and requires a degree of experience to avoid traps
avoid opiates and tramadol in back pain as evidence suggests they are of little benefit over non-steroidal anti-inflammatory drugs (NSAIDs) and do more harm, especially for chronic pain, instead consider a stat dose of corticosteroids such as 75mg prednisolone if acute disabling disc prolapse pain
most patients DO NOT warrant a lumbo-sacral Xray as these are high radiation procedures and usually have a low pick up rate
consider CT scan if significant trauma, or MRI if acute low back pain and specific indications - see BELOW!
one of the first steps in assessing these patients in ED is to determine the pain pattern to better direct you down the correct path:
is it lower abdominal pain radiating to the back - think gynaecologic causes such as dysmenorrhoea, miscarriage, endometriosis, imperforate hymen in puberty
consider FBE, U&E, LFTs, lipase and CRP on most adult patients with back pain without clear cause, and especially if they are immunocompromised or are an IVDU
occult seeding of bacteria to the spine may not present with fever and is important to detect early
underlying disease, immunosuppression, penetrating wound, intravenous drug use, recent staph infection, recent acupuncture or dry needling
sacro-iliac septic arthritis
unilateral tenderness over PSIS, usually with fever
this is a rare condition and is usually staphylococcal but can be salmonella
may occur after normal vaginal delivery (possible role of epidural or spinal anaesthesia but this is unclear as it is usually haematogenous spread or perhaps following local steroid injection)
risk factors are as for spinal sepsis (see above)
MRI is the best Ix and may show fluid over lumbosacral plexus and psoas muscles with associated myositis
Rx is IV antibiotics with staph coverage; usually not able to be drained, and thus generally admitted under ID.
urinary and/or faecal incontinence or retention, of recent onset
in addition, consider urgent MRI for potential cause equina onset in those who have no neurology but severe and unrelenting low back pain of acute onset
this is an indication for MRI scan preferably on day of onset as delay in Rx may increase risk of permanent urinary disturbances