An Evidence-Based Approach To The Evaluation And Treatment Of Low Back Pain In The Emergency Department
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An Evidence-Based Approach To The Evaluation And Treatment Of Low Back Pain In The Emergency Department

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Table of Contents
 
Table of Contents
  1. Abstract
  2. Case Presentation
  3. Introduction
  4. Critical Appraisal Of The Literature
  5. Epidemiology
  6. Pathophysiology
    1. Definitions
  7. Differential Diagnosis
    1. Epidural Abscess
    2. Abdominal Aortic Aneurysm
    3. Cauda Equina Syndrome
    4. Spinal Epidural Hematoma
  8. Prehospital Care
  9. Emergency Department Evaluation
  10. Diagnostic Studies
    1. Imaging
    2. Emergency Department Ultrasound
    3. Laboratory Testing
  11. Treatment
    1. Measuring Effectiveness Of Treatment
    2. Pharmacologic Treatment
      1. Acetaminophen
      2. Nonsteroidal Anti-Inflammatory Drugs
      3. Muscle Relaxants
      4. Topical Medications
      5. Neuropathic Pain Medications
      6. Antidepressants
      7. Opioid Analgesics
      8. Systemic Steroids
    3. Nonpharmacologic Treatment For Acute And Chronic Lower Back Pain
      1. Bed Rest
      2. Education And Back Schools
      3. Behavioral Therapy
      4. Exercise Therapy And Yoga
      5. Massage
      6. Heat
      7. Transcutaneous Electrical Nerve Stimulation
      8. Acupuncture
      9. Spinal Manipulation
    4. Surgical Treatment Of Back Pain
      1. Fusion
      2. Surgery For Radiculopathy
      3. Decompressive Surgery For Spinal Stenosis
  12. Special Circumstances
    1. The Pediatric Patient
  13. Controversies And Cutting Edge
  14. Disposition
  15. Summary
  16. Risk Management Pitfalls For Low Back Pain
  17. Time- And Cost-Effective Strategies
  18. Case Conclusion
  19. Clinical Pathway For Management Of Low Back Pain In The Emergency Department
  20. Tables and Figures
    1. Table 1. Relevant Practice Guidelines For Low Back Pain
    2. Table 2. Differential Diagnosis For Lower Back Pain
    3. Table 3. Red Flag History And Physical Examination Findings
    4. Table 4. Affected Nerve Roots And Their Corresponding Neurologic Examination Findings
    5. Table 5. The Waddell Signs And Score
    6. Table 6. Low Back Pain Interventions%2C Summary Of Evidence Level And Grade
    7. Figure 1. General Anatomy Of The Lumbar Spine
    8. Figure 2. Summary Of Neurologic Examination At L4-S1 Levels
    9. Figure 3. Osteomyelitis And Abscess
    10. Figure 4. Posterior Disc Herniation
    11. FIgure 5. Sample of Discharge Instructions
  21. References

Abstract

Low back pain is the most common musculoskeletal complaint that results in a visit to the emergency department, and it is 1 of the top 5 most common complaints in emergency medicine. Estimates of annual healthcare expenditures for low back pain in the United States exceed $90 billion annually, not even taking lost productivity and business costs into account. This review explores an evidence-based rationale for the evaluation of the patient with low back pain, and it provides guidance on risk stratification pertaining to laboratory assessment and radiologic imaging in the emergency department. Published guidelines from the American College of Physicians and American Pain Society are reviewed, with emphasis on best evidence for pharmacologic treatments, self-care interventions, and more invasive procedures and surgery in management of low back pain. Utilizing effective and proven strategies will avoid medical errors, provide better care for pa- tients, and help manage healthcare resources and costs.

Key Words: low back pain, herniated disc, sciatica, cauda equina syndrome, radiculopathy, NSAID, acetaminophen, muscle relaxant, opioid, fusion, discectomy, laminectomy, epidural steroid injection

Case Presentation

A 45-year-old man presents after 7 days of pain in his lower back. He reports that it began the day after he started at a new job site. The pain initially improved with ibupro- fen, but he woke up this morning with a severe exacerba- tion of the pain. He denies a fall or other trauma, and he states that the pain radiates from his left buttock to his left foot. He has had intermittent back pains in the past, but he never required any imaging or interventions. Employed in the construction industry, he has a history of hypertension and is going through a divorce. He is afebrile, has a benign abdominal exam, and displays an antalgic gait. He has intact patella and Achilles reflexes, and he has a positive left straight-leg raise sign and crossed straight-leg raise sign. Strength and sensation, including the perineum, are intact and symmetrical. The patient insists that he needs an MRI and requests a note for 2 weeks off from work...

As you are considering your first patient’s requests, a 27-year-old woman is placed in the next room, also com- plaining of lower back pain. You review her past visits and see that she has been to the ED several times in the past 6 months for various complaints, including headache, tooth- ache, and pain after an assault. She has had pain in her up- per lumbar area for 1 week, and it is exacerbated with any change in body position. She has no pain in her legs and no weakness or numbness, although she says that it feels as if her back is swollen. She insists she has never had back problems in the past, and there has been no trauma. She has a normal heart and lung exam and no abdominal tender- ness. There is no costovertebral angle tenderness, and she seems tender around the L1 area. You write a prescription for NSAIDs and go off to see your next patient. When you return to finish your evaluation, you note that the patient had a fever of 38.9°C. She has already left the ED, and the phone number she left is disconnected; however, before the end of your shift, she is returned to the ED by EMS, with a fever of 39.4°C. You have a sinking feeling that maybe you were too quick to judge this patient’s complaint...

Introduction

Low back pain is the most common musculoskel- etal complaint that is evaluated in the emergency department (ED), and it affects most adults at some point in their lives.1 The Edwin Smith papyrus, a collection of Egyptian documents from 1600 BC, and one of the oldest medical texts, describes 48 patient cases. It includes a patient with a pulled vertebra and recommends “...you have to put him stretched out... ” Unfortunately, this was patient case number 48, the last scroll, and the rest of the scroll is missing; hence the medical field has been without clear guid- ance for this condition for over 3500 years.2 In the intervening time, we have developed extraordinary tools to noninvasively visualize spinal anatomy,and we have elucidated a molecular mechanism of neurotransmission, yet we are still challenged by the many elements that constitute how humans feel and interpret pain. Interspersed between the patients with musculoskeletal back pain are patients with back pain who are at risk for permanent neurologic or even life-threatening sequela because they are harboring lesions that require timely diagnosis and treatment. By utilizing a focused approach, the ED clinician will be able to identify these “red flag” symptoms in patients and initiate a workup. This is- sue of Emergency Medicine Practice reviews the prog- ress to date on developing a standardized, focused approach and guides the clinician to rationally and cost-effectively evaluate the patient presenting with low back pain symptoms.

Critical Appraisal Of The Literature

The study of low back pain is plagued by the fact that it is not a single pathologic entity. In addition, pain is a subjective complaint that can be measured only indirectly, and these measurements are influenced by cognitive and behavioral factors as well as secondary gains. There are many back pain treatments available, and the randomized controlled trials available do not necessarily compare 1 treatment with placebo; instead, 1 treatment is compared with a multitude of other interventions, adding difficulty to making pooled data samples that are typical of systematic reviews and meta-analyses. There are long-term studies available, however, and the natural history of low back pain is very well described, so, for the most part, prognostic conclusions are well supported.

A literature search was performed utilizing PubMed, as well as Ovid MEDLINE® and the Co- chrane Database of Systematic Reviews from 1990 to the present. Search terms included low back pain and back pain, and these terms were joined with imaging medication classes (NSAID, acetaminophen, muscle relaxant, opioid), as well as specific therapies (fusion, diskectomy/discectomy, laminectomy, epidural steroid, injection, acupuncture, spinal manipulation), and were limited to English literature and human studies. Papers with prospective randomized methodologies were initially reviewed, and references most frequently mentioned in the discussion sections of these papers were reviewed as well. These searches produced guidelines by the American College of Physicians in association with the American Pain Society3 as well as recommendations from the National Health Service in the United Kingdom,4 an imaging guideline from the American College of Radiology,5 and opioid prescription guidelines from the Ameri- can College of Emergency Physicians.6 (See Table 1.)

Risk Management Pitfalls For Low Back Pain

  1. “I didn’t realize that he had a prior history of melanoma that was resected 2 years ago.” Red flag signs, symptoms, and history are essential in the management of these patients. While some of these syndromes (eg, cauda equina syndrome, epidural abscess) are uncommon in the general population, they become a real possibility in the patient with metastatic cancer or in the patient who injects drugs.
  2. “My 70-year-old male patient with back pain had syncope in the waiting room and was rushed to the trauma bay. I thought the systolic pressure of 70 mm Hg was just an error, as the repeat was 120 mm Hg.” More thought needs to be given to older patients with back pain, as their symptoms may be arising not from typical muscular/discogenic/degenerative joint disease sources; they may be harboring a leaking abdominal aortic aneurysm or metastatic cancer. Consider systemic symptoms such as weight loss, fever, abdominal pain, and syncope as well as risk for peripheral vascular disease.
  3. I remember seeing this patient 4 times this past year for toothache and headache. Now he has back pain! He does have a fever this time though, very clever!” Even patients who are drug-seeking have real back pain. Some patients who inject drugs have infections that are the cause of this pain. There is no single laboratory test or examination finding that will rule out vertebral osteomyelitis or discitis.
  4. “The patient in bay 3 status post motor vehicle collision looks familiar. Oh yes, I just saw him for low back pain.” The medications prescribed for back pain can cause sedation; especially muscle relaxants in combination with opioids. Be sure to remind patients that they should not drive or perform dangerous tasks while using them.
  5. “While I was waiting for the patient to be discharged, he had a tonic-clonic seizure.” Know the side effects of the medications that you prescribe. Tramadol can decrease the seizure threshold and should not be used in patients who are at risk for seizure. Risk Management Pitfalls For Low Back Pain
  6. “The patient told me he has had back pain and urinated on himself. I was very concerned and transferred him for emergency MRI. The MRI was normal, and I don’t understand why.” Overflow incontinence and urinary retention are worrisome findings and do require emergent evaluation. However, sometimes patients just cannot make it to the bathroom because of back pain and physical limitations. Determining the cause of incontinence and assessing for postvoid residuals will improve imaging utilization.
  7. “The patient was just seen by the pain management specialist and had an epidural steroid injection yesterday. He is here again with back pain, and he cannot walk. He seems weak in his legs, but that’s just pain.” Patients who are status postprocedure are at increased risk for developing complications that include epidural hematoma and spinal infection. These patients need imaging if they have new neurologic findings.
  8. “This patient has new paraspinal back pain and atrial fibrillation and is on warfarin. He has a hematocrit of 25, down 10 points, and is guaiac negative. His international normalized ratio is 4.8. His neurologic examination is unrevealing. I am going to send him home.” Be more vigilant in patients with other medical problems who are on medications that cause bleeding. This patient could return to the ED after a syncopal episode and have a retroperitoneal hemorrhage.
  9. “I just saw a 36-weeks’ pregnant female with paraspinal/flank pain and mild nausea. I evaluated her baby with bedside ultrasound, and things seemed normal. I planned to discharge her, but then I found she had a fever of 38.3°C.” While back pain and sciatica are common in pregnancy, you should consider other causes in your differential. This patient could also have a urinary tract infection.
  10. “I should have thought of other causes of urinary retention in this 67-year-old male patient before placing the catheter and sending him home for urology follow-up.” Advanced age is a red flag sign; instead of benign prostatic hyperplasia with back pain, he could have had prostate cancer with spinal metastasis and cauda equina syndrome.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

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Publication Information
Authors

Pierre Borczuk, MD

Publication Date

July 2, 2013

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