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Emergency and Acute Medicine – Back Pain
Overview and Definitions
Low back pain (LBP) refers to pain localized between the lower rib cage and the gluteal folds and may radiate into the thighs. Sciatica describes pain following the distribution of lower lumbar nerve roots and may be associated with sensory or motor deficits. Pain is classified as acute when lasting less than 6 weeks, subacute when lasting 6–12 weeks, and chronic when persisting longer than 12 weeks.
Etiology
The majority of cases arise from nonspecific musculoligamentous sources involving muscles, ligaments, or fascia. Other causes include nucleus pulposus herniation, degenerative disc or facet joint disease, spinal stenosis, and anatomic abnormalities such as spondylolisthesis. Fractures may occur following trauma or osteoporosis. Less commonly, back pain results from systemic disease including malignancy, infection, vascular pathology such as aortic dissection or aneurysm, renal disease, gastrointestinal conditions, or pelvic organ pathology.
Clinical Features
Musculoligamentous pain is typically dull, poorly localized, and confined to the back or gluteal region without radiation beyond the knee and without objective neurologic deficits. Sciatica presents as sharp, shooting pain with leg symptoms often more prominent than back pain and may include dermatomal sensory loss, asymmetric reflexes, or weakness. Massive central disc herniation causing cauda equina syndrome presents with decreased perineal sensation, urinary retention with overflow incontinence, and fecal incontinence. Infectious causes are suggested by fever and focal vertebral percussion tenderness. Bony lesions produce constant pain unrelieved by rest and may be accompanied by constitutional symptoms. Vascular etiologies cause severe, tearing pain and may be associated with cold or insensate extremities.
History and Examination
History assists in narrowing the differential and identifying high-risk pathology by assessing pain intensity, quality, location, radiation, onset, aggravating or relieving factors, psychosocial contributors, and response to prior therapy. Red flags include fever, weight loss, trauma, age greater than 60 years, malignancy with bone metastasis potential, chronic steroid use, IV drug use, recent bacteremia or instrumentation, and nocturnal pain. Physical examination should assess for fever, vertebral tenderness, straight-leg raise testing, motor strength of L5–S1, ankle reflexes, dermatomal sensation including saddle anesthesia, and rectal sphincter tone when indicated.
Essential Evaluation
A thorough history and physical examination including neurologic and vascular assessment are sufficient for uncomplicated musculoligamentous or sciatic pain. No routine testing is required unless concerning features are present. Rapid diagnostic testing and vascular consultation are required when an aortic etiology is suspected.
Diagnostic Testing
Urinalysis is indicated when urinary infection or prostatitis is suspected. ESR is sensitive but nonspecific for infectious or inflammatory disease and may be used as a screening tool. Lumbosacral radiographs are indicated for significant trauma, age over 50–60 years, fever, IV drug use, malignancy, pain at rest, or lack of improvement after 4 weeks. Bedside ultrasound may identify urinary retention or abdominal aortic aneurysm. MRI is indicated for suspected epidural abscess, malignancy, hematoma, rapidly progressive neurologic deficits, or bowel or bladder dysfunction. CT is useful when MRI is unavailable and is the test of choice for unstable fractures or vascular pathology in stable patients.
Differential Diagnosis
Spinal causes include musculoligamentous pain, disc disease, fractures, spondylolisthesis, ankylosing spondylitis, osteomyelitis, epidural abscess or hematoma, and neoplasm. Nonspinal causes include abdominal aortic aneurysm, aortic dissection, prostatitis, upper urinary tract infection, renal colic, and abdominal malignancy.
Management
NSAIDs and acetaminophen are first-line therapy for musculoligamentous pain but are ineffective for sciatica. Muscle relaxants may provide benefit but are limited by sedation and anticholinergic effects. Short courses of opioids may be considered for severe pain refractory to first-line therapy. Corticosteroids show no benefit in radicular or nonradicular back pain. Spinal manipulation may help selected patients with acute pain. Early mobilization is preferred, as prolonged bed rest delays recovery. Heat therapy may provide short-term benefit. Physical therapy may assist with symptom control and prevention of recurrence, which is common.
Disposition and Follow-Up
Admission is indicated for severe pain with inability to ambulate, progressive neurologic deficits, cauda equina syndrome, or infectious, vascular, or neoplastic causes. Patients with uncomplicated back pain may be discharged once pain is controlled and ambulation is possible. Follow-up with primary care is recommended within 1–2 weeks, sooner for neurologic symptoms.
Key Clinical Insights and Diagnostic Traps
Maintain a high index of suspicion for epidural abscess in patients with IV drug use. Elderly patients may sustain fractures after minimal trauma. New-onset back pain in older adults warrants evaluation for vascular pathology. Patients should be counseled that recovery is often prolonged and recurrence is common. Opioid prescriptions from the ED should be limited in duration.
Overview and Definitions
Low back pain (LBP) refers to pain localized between the lower rib cage and the gluteal folds and may radiate into the thighs. Sciatica describes pain following the distribution of lower lumbar nerve roots and may be associated with sensory or motor deficits. Pain is classified as acute when lasting less than 6 weeks, subacute when lasting 6–12 weeks, and chronic when persisting longer than 12 weeks.
Etiology
The majority of cases arise from nonspecific musculoligamentous sources involving muscles, ligaments, or fascia. Other causes include nucleus pulposus herniation, degenerative disc or facet joint disease, spinal stenosis, and anatomic abnormalities such as spondylolisthesis. Fractures may occur following trauma or osteoporosis. Less commonly, back pain results from systemic disease including malignancy, infection, vascular pathology such as aortic dissection or aneurysm, renal disease, gastrointestinal conditions, or pelvic organ pathology.
Clinical Features
Musculoligamentous pain is typically dull, poorly localized, and confined to the back or gluteal region without radiation beyond the knee and without objective neurologic deficits. Sciatica presents as sharp, shooting pain with leg symptoms often more prominent than back pain and may include dermatomal sensory loss, asymmetric reflexes, or weakness. Massive central disc herniation causing cauda equina syndrome presents with decreased perineal sensation, urinary retention with overflow incontinence, and fecal incontinence. Infectious causes are suggested by fever and focal vertebral percussion tenderness. Bony lesions produce constant pain unrelieved by rest and may be accompanied by constitutional symptoms. Vascular etiologies cause severe, tearing pain and may be associated with cold or insensate extremities.
History and Examination
History assists in narrowing the differential and identifying high-risk pathology by assessing pain intensity, quality, location, radiation, onset, aggravating or relieving factors, psychosocial contributors, and response to prior therapy. Red flags include fever, weight loss, trauma, age greater than 60 years, malignancy with bone metastasis potential, chronic steroid use, IV drug use, recent bacteremia or instrumentation, and nocturnal pain. Physical examination should assess for fever, vertebral tenderness, straight-leg raise testing, motor strength of L5–S1, ankle reflexes, dermatomal sensation including saddle anesthesia, and rectal sphincter tone when indicated.
Essential Evaluation
A thorough history and physical examination including neurologic and vascular assessment are sufficient for uncomplicated musculoligamentous or sciatic pain. No routine testing is required unless concerning features are present. Rapid diagnostic testing and vascular consultation are required when an aortic etiology is suspected.
Diagnostic Testing
Urinalysis is indicated when urinary infection or prostatitis is suspected. ESR is sensitive but nonspecific for infectious or inflammatory disease and may be used as a screening tool. Lumbosacral radiographs are indicated for significant trauma, age over 50–60 years, fever, IV drug use, malignancy, pain at rest, or lack of improvement after 4 weeks. Bedside ultrasound may identify urinary retention or abdominal aortic aneurysm. MRI is indicated for suspected epidural abscess, malignancy, hematoma, rapidly progressive neurologic deficits, or bowel or bladder dysfunction. CT is useful when MRI is unavailable and is the test of choice for unstable fractures or vascular pathology in stable patients.
Differential Diagnosis
Spinal causes include musculoligamentous pain, disc disease, fractures, spondylolisthesis, ankylosing spondylitis, osteomyelitis, epidural abscess or hematoma, and neoplasm. Nonspinal causes include abdominal aortic aneurysm, aortic dissection, prostatitis, upper urinary tract infection, renal colic, and abdominal malignancy.
Management
NSAIDs and acetaminophen are first-line therapy for musculoligamentous pain but are ineffective for sciatica. Muscle relaxants may provide benefit but are limited by sedation and anticholinergic effects. Short courses of opioids may be considered for severe pain refractory to first-line therapy. Corticosteroids show no benefit in radicular or nonradicular back pain. Spinal manipulation may help selected patients with acute pain. Early mobilization is preferred, as prolonged bed rest delays recovery. Heat therapy may provide short-term benefit. Physical therapy may assist with symptom control and prevention of recurrence, which is common.
Disposition and Follow-Up
Admission is indicated for severe pain with inability to ambulate, progressive neurologic deficits, cauda equina syndrome, or infectious, vascular, or neoplastic causes. Patients with uncomplicated back pain may be discharged once pain is controlled and ambulation is possible. Follow-up with primary care is recommended within 1–2 weeks, sooner for neurologic symptoms.
Key Clinical Insights and Diagnostic Traps
Maintain a high index of suspicion for epidural abscess in patients with IV drug use. Elderly patients may sustain fractures after minimal trauma. New-onset back pain in older adults warrants evaluation for vascular pathology. Patients should be counseled that recovery is often prolonged and recurrence is common. Opioid prescriptions from the ED should be limited in duration.
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