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back pain in the ED


  • 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

red flags

  • osteomyelitis, vertebral osteomyelitis / discitis, paraspinal/spinal cord abscesses
    • fever
    • risk factors for spinal bacterial infection:
      • 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.
  • spinal tuberculosis (TB) (Pott's disease)
    • no fever, no redness, chronic course, usually thoracic or lumbar spine which is tender, there may be kyphosis from destruction of spine
    • less than 40% have extra-skeletal TB
    • neurology may occur early
    • large, cold abscesses of paraspinal tissues or psoas muscle may protrude under the inguinal ligament and may erode into the perineum or gluteal area
    • upper Cx spine cases can be rapidly progressive and cause early neurology and retropharyngeal abscesses
    • plain XR if suspicious
    • spinal tuberculosis should always be suspected when radiographs demonstrate a destructive spinal process.
  • fracture risk?
    • major trauma
    • minor trauma, if >50 years old, with a history of osteoporosis, and/or taking corticosteroids
    • mechanism of injury for possible unstable Chance fracture - hyperflexion such as MVA with lap belt or fall from a height
    • PH malignancy
    • >50 years old
    • Unexplained weight loss (e.g. >4.5kg in <6 months)
    • Pain at multiple sites
    • Pain at rest
    • Sudden onset
    • Associated collapse/hypotension
    • Pain not aggravated by spinal movement
    • Abdominal pain radiating to back
    • low index of suspicion - consider ED bedside USS or CT scan ASAP
    • saddle anaesthesia
    • 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
  • risk of retroperitoneal haemorrhage:
    • anticoagulants or bleeding diasthesis
    • renal or adrenal tumours
    • connective tissue disease or vasculitis

potential indications for same day CT scan

  • high impact trauma with possible unstable Chance fracture or other spinal fracture such as
    • MVA - especially if wearing lap belt at speed
    • acute axial loading - fall from height onto feet
    • acute hyperflexion
  • suspected retroperitoneal haemorrhage
  • suspected renal trauma (usually a contrast CT is indicated)
  • suspected AAA (preferably contrast CT aortogram)
  • suspected renal colic and either single kidney, suspected sepsis or severe pain not resolving (CT KUB)

potential indications for same day MRI scan with acute low back pain

  • evidence of cauda equina syndrome such as either:
    • new urinary symptoms or urinary retention
    • faecal incontinence
    • saddle anaesthesia
  • suspected or possible spinal infection
    • see above
  • severe neurologic deficits
  • suspected neoplastic aetiology
    • history of cancer with new onset pain

potential indications for delayed consideration of MRI pending trial of Rx

  • lower probability of neoplastic aetiology
    • unexplained LOW, age > 50yrs, ESR > 100, or h'crit < 30%
  • possible ankylosing spondylitis
    • morning stiffness improves with exercise
    • alternating buttock pain
    • awakening in 2nd part of night due to back pain
    • age 20-40yrs
  • possible spinal stenosis and potential candidates for surgery
    • older age
    • pseudoclaudication
    • radiating leg pain
  • radiculopathy and potential candidates for surgery
    • sciatica with pain in L4, L5 or S1 distribution
    • positive SLR test
  • suspected vertebral fracture
    • consider plain XRay first
    • 2 or more risk factors: corticosteroids, age > 70, female, significant trauma

potential indications for plain L/S Xray

  • suspected vertebral fracture
    • 2 or more risk factors: corticosteroids, age > 70, female, significant trauma
    • but if Xray negative, still consider an MRI

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backpain.txt · Last modified: 2020/02/01 01:10 by

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