Emergency Department Management of Patients With Low Back Pain: A Review of Current Evidence

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Publication Date: November 2024 (Volume 26, Number 11)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 11/01/2027.

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Peer Reviewers

Abstract

Low back pain is a common presentation in the emergency department, and determining whether the cause is benign or life-threatening can be challenging. A systematic strategy for the history and physical examination can help reduce unecessary imaging, and an evidence-based approach will inform safe and effective pain management recommendations. This issue reviews the evidence on red flag signs and symptoms for low back pain, current diagnostic studies recommendations, and best-practice treatment and disposition strategies.

Case Presentations

A 57-year-old woman presents to the ED with back pain…

• She arrives clutching her back and limps to the gurney. She said she has had low back pain before, but it is more severe today.
• Her vital signs are: temperature, 36.7°C; heart rate, 95 beats/min; blood pressure, 161/95 mm Hg; respiratory rate, 22 breaths/min; and oxygen saturation, 98% on room air.
• On examination, you elicit pain, without radiation, with palpation of her right lower back and elevation of her leg. You wonder whether this presentation warrants imaging and how best to treat her pain...

A 41-year-old man arrives with new-onset urinary incontinence…

• For 4 days, he has had difficulty controlling his urination. Yesterday, he developed low back pain, and his legs gave out when he got out of bed.
• His vital signs are: temperature, 37.8°C; heart rate, 104 beats/min; blood pressure, 142/87 mm Hg; respiratory rate, 20 breaths/min; and oxygen saturation, 100% on room air.
• On examination, the patient is warm to touch, but he is not in distress. He has midline tenderness to palpation of his lower thoracic spine, and bilateral lower extremity weakness. This presentation is concerning for its “red-flag” findings, but your facility does not have MRI. You wonder how emergent the diagnostic testing needs to be, and how best to expedite management...

An 81-year-old man is brought in by EMS due to sudden-onset left-sided low back pain…

• He has a history of low back pain, but it intensified suddenly in a different location. He says he has been a life-long cigarette smoker.
• His vital signs are: temperature, 37°C; heart rate, 124 beats/min; blood pressure, 81/52 mm Hg, respiratory rate, 18 breaths/min; and oxygen saturation, 96% on room air.
• He appears cool, clammy, and diaphoretic, and he is in distress. He has no focal weakness or neurologic findings on examination. This is clearly more than a muscle strain, and you wonder what the best test would be to evaluate the cause of his back pain and hypotension…

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