User Tools

Site Tools


acute thoracic back pain in the adult


  • back pain can be a very deceptive presentation, all too easily put down to muscle strain 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 chronic back pain as evidence suggests they are of little benefit over non-steroidal anti-inflammatory drugs (NSAIDs) and do more harm
  • most patients DO NOT warrant a thoracic spine Xray as these are high radiation procedures and usually have a low pick up rate
    • consider plain XR or CT scan if acute low back pain and not pregnant, and either:
      • high impact trauma
      • osteoporotic or over 50yrs age with a fall
      • fall from a height

differential diagnoses based on anatomic causes

  • BEWARE the IVDU or the immunocompromised who are at risk of septic seeding to the spine
  • if there is unexplained fever or acute neurology check inflammatory markers and consider emergent MRI
  • remember chest pain plus neurology or chest pain radiating to back, you need to strongly consider aortic dissection

a diagnostic approach

patient with obvious emergency red flag

  • manage according to red flag such as:
    • trauma to thoracic spine - manage as per thoracic spine trauma
    • presenting features suggestive of aortic dissection or abdominal aortic aneurysm (AAA) (eg. severe pain radiating to back which is not clearly biliary, or hypotension)
    • acute neurology - spinal precautions and emergent imaging
    • fever or sepsis - manage as per sepsis / septicaemia and search for cause
      • tender abdomen - consider abdominal CT scan if not biliary (in which case fasting biliary USS may be better if time allows)
      • CXR +/- thoracic spine views
      • urinalysis +/- MSU m/c/s
      • if midline vertebral tenderness or neurology - emergent MRI
  • emergent MRI scan if
    • clinical features of cauda equina syndrome (CES)
    • unexplained new neurology
    • 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

no obvious red flags

  • detailed history and exam to search for likely cause and best approach to investigation, in particular:
    • history of the pain and was there trauma?
    • could the patient be pregnant? (this will affect analgesia options, radiology, and raise possibility of PE or ruptured ectopic as causes)
    • is there a history of fevers or chills, cough, SOB, calf pain, dissection risk factors
    • overseas travel
    • VTE risk factors
    • past history tuberculosis (TB), neoplasia / cancer / tumours, recent sepsis / septicaemia, surgery to spine or thorax
    • is there an obvious herpes zoster (shingles) rash, or could it be post-zoster neuralgia
    • where is the tenderness?
    • double check for acute neurology
    • double check it is not referred pain from abdomen
    • urinalysis to exclude acute pyelonephritis, esp. if there is flank tenderness
    • immunocompromised, IVDU or recent staphylococcal infection - consider inflammatory markers

Clinical features of thoracic nerve impingement

backpain_thoracic_adult.txt · Last modified: 2021/09/30 16:23 by gary1