first read: back pain in the ED

see also orthopaedics in the ED

• pyelonephritis
• renal colic
• abdominal aortic aneurysm (AAA)
• dissection thoracic aorta (usually have chest pain ⇒ back with PH hypertension)
• crush fracture Tx/Lx spine
• metastatic pathologic fractures
• lumbar facet joint degenerative arthropathy - morning stiffness and chronic low back pain in older adults - accounts for up to 50% of chronic low back pains
• acute spinal cord compression from metastases
• penetrating peptic ulcer
• spondylolisthesis due to subluxation resulting from degenerative changes
• spinal stenosis - esp. wrestlers, weight-lifters, and others over 60yrs age
• uncommonly:
  • acute disc prolapse - uncommon to have onset > 50yrs age.
  • hypercalcaemia

• exclude AAA early - if epigastrium is tender discuss with ED consultant for urgent US or CT
• if chest pain radiating to back - exclude dissection, PE, pneumothorax, etc.
• urinalysis as above under adults
• lower threshold for plain Xrays of Tx or Lx spine as even minor injury such as a trip/fall can cause a crush fracture in osteoporotic elderly or those with occult metastatic disease.
• look carefully for neurology in lower limbs & esp. bladder/bowel dysfunction which may indicate acute spinal cord compression and need for urgent neurosurgical assessment.
• take extra care in prescribing NSAID's - risk of gastric bleed; avoid if on ACE inhibitors as risk of renal failure.