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The adult with back pain in the ED


essentials of ED Mx:

  • if IVDU, diabetic, immunocompromised or history of fever, exclude sepsis - do a FBE and CRP, and if raised consider emergent MRI
  • avoid spine Xrays unless absolutely necessary as high radiation dose to gonads, and ensure not pregnant, and yield is not high unless either:
    • significant trauma
    • compressive trauma such as landing on feet from a height
    • severe hyperflexion such as a MVA lap belt injury or fall from height resulting in an unstable Chance fracture
    • risk of osteoporosis or pathological fracture
    • NB. CT scan is probably better risk benefit than plain Xrays if searching for a fracture
  • if epigastric pain then consider:
    • PU - erect CXR for free gas
    • AAA in the older adult > 50yrs (see below)
  • if severe colicky pain, rolling around in bed then peritonism and musculoskeletal pain is unlikely, think renal colic or perhaps biliary colic
  • if midline tenderness with either fever or raised inflammatory markers, consider MRI scan for bacterial vertebral osteomyelitis / discitis (this can be life threatening)
  • urinalysis:
    • if haematuria without leukocytes/nitrites, consider renal colic but absence of haematuria does not exclude it.
    • if large leukocytes &/or nitrites, consider acute pyelonephritis
  • emergent MRI scan if
    • clinical features of cauda equina syndrome (CES)
    • unexplained new neurology - not just a single lower limb radiculopathy (these could be managed with an OP MRI)
    • unexplained pain/neurology in context of coagulopathy/warfarin Rx - may be retroperitonal haemorrhage or a spinal epidural haematoma
    • unexplained raised CRP esp. if IVDU with back pain
  • if sciatica, assess as per approach to sciatica
    • consider combinational Rx early - non-steroidal anti-inflammatory drugs (NSAIDs), paracetamol (+/- oxycodone if very severe and unlikely to go home although opiates should be avoided where possible in most patients with back pain)
    • document SLR, neurology such as reflexes, lower limb neurology, bladder/bowel function
    • care coordinator to assess mobility, etc
    • if unlikely to be able to mobilise sufficiently to go home, then discuss with ED senior for possible admission under general medicine or into EOU if likely to be able to go home next day
    • CT scan or MRI scan for low back pain is very unlikely to be helpful IF there are no red flags such as possible cauda equina syndrome, tumour, fracture or possible spinal abscess/discitis/haematoma
      • MRI scan in the absence of red flags, whilst giving information regarding the status of discs, does not improve the back pain but does increase the risk of neurosurgical referral, and potential neurosurgery procedure despite the fact that long term outcomes of these procedures are similar to patients not having these procedures1)
    • finally, consider assessing yellow flags for identifying psychosocial barriers to recovery:
      • ascertain the following potential barriers:
        • presence of beliefs that back pain is harmful or potentially severely disabling
        • fear-avoidance behaviour (avoiding a movement or activity due to misplaced anticipation of pain) and reduced activity levels
        • tendency to low mood and withdrawal from social interaction
        • an expectation that passive treatments rather than active participation will help.
      • ask about:
        • Have you had time off work in the past with back pain?
        • What do you understand is the cause of your back pain?
        • What are you expecting will help you?
        • How is your employer responding to your back pain? Your co-workers? Your family?
        • What are you doing to cope with back pain?
        • Do you think that you will return to work? When?
  • if sacro-iliitis, check skin, nails for psoriasis, consider Xray for ankylosing spondylitis features, if male, ask about features of Reiter's
  • if chest pain radiating to back - exclude dissection, PE, pneumothorax, etc.
backpain_adult.txt · Last modified: 2022/09/30 01:26 by wh

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