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

Table of Contents

 

About This Issue

Low back pain (LBP) in emergency department patients is typically the result of relatively benign causes, but emergency clinicians must be vigilant in identifying the red-flag signs that can signal potential disability, death, and legal liability. In this issue you will learn:

What are the likelihood ratios of red-flag findings in patients with LBP?

How can the key signs of cauda equina syndrome be differentiated from sciatica, spinal stenosis, and disk herniation?

What are the risk factors for infectious causes of LBP?

What percentage of patients with spinal epidural abscess present with the classic triad of fever, back pain, and neurologic deficits?

What might be the cause of pain referred to the low back, and can they be life-threatening?

Are laboratory studies helpful when there is suspicion for infectious causes of LBP?

X-ray, CT, and MRI: which test (if any) is best?

What are the indications for emergent surgical consult?

Are there any medications or nonpharmacologic therapies that show evidence of usefulness?

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Mechanical
      1. Intervertebral Disc Herniation
      2. Fracture
      3. Compression Syndromes
         1. Spinal Epidural Hematoma
      4. Sciatica
      5. Spondylosis
      6. Compartment Syndrome
   2. Infectious
      1. Spondylodiscitis
      2. Spinal Epidural Abscess
   3. Inflammatory
   4. Referred Pain
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
      1. Compression and Mechanical Causes
         1. Conus Medullaris Syndrome
         2. Cauda Equina Syndrome
         3. Malignancy
         4. Fracture
         5. Spinal Stenosis and Herniation
      2. Infectious Causes
      3. Referred Pain Causes
   2. Physical Examination
10. Diagnostic Studies
    1. Laboratory Testing
    2. Imaging Studies
       1. X-ray
       2. Computed Tomography
       3. Magnetic Resonance Imaging
       4. Ultrasound
11. Treatment
    1. Treatment of Emergent Causes of Back Pain
    2. Treatment for Nonspecific Back Pain
       1. Nonsteroidal Anti-Inflammatory Drugs
       2. Acetaminophen
       3. Skeletal Muscle Relaxants
       4. Opioids
       5. Corticosteroids
       6. Diazepam
       7. Gabapentin
       8. Trigger Point Injections
       9. Nonpharmacologic Management
12. Controversies and Cutting Edge
13. Disposition
14. Summary
15. Time- and Cost-Effective Strategies
16. Risk Management Pitfalls in Emergency Department Management of Patients With Low Back Pain
17. 5 Things That Will Change Your Practice
18. Case Conclusions
19. Clinical Pathways
    1. Clinical Pathway for Low Back Pain in Emergency Department Patients With Normal Vital Signs
    2. Clinical Pathway for Low Back Pain in Emergency Department Patients With Abnormal Vital Signs
20. Tables and Figures
21. References

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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Clinical Pathway for Low Back Pain in Emergency Department Patients With Normal Vital Signs

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

20. * Galliker G, Scherer DE, Trippolini MA, et al. Low back pain in the emergency department: prevalence of serious spinal pathologies and diagnostic accuracy of red flags. Am J Med. 2020;133(1):60-72. (Systematic review; 22 studies) DOI: 10.1016/j.amjmed.2019.06.005

25. * Friedman BW, Mulvey L, Davitt M, et al. Predicting 7-day and 3-month functional outcomes after an ED visit for acute nontraumatic low back pain. Am J Emerg Med. 2012;30(9):1852-1859. (Prospective study; 556 patients) DOI: 10.1016/j.ajem.2012.03.027

29. * Dionne N, Adefolarin A, Kunzelman D, et al. What is the diagnostic accuracy of red flags related to cauda equina syndrome (CES), when compared to magnetic resonance imaging (MRI)? A systematic review. Musculoskelet Sci Pract. 2019;42:125-133. (Systematic review; 7 studies) DOI: 10.1016/j.msksp.2019.05.004

46. * Chou R, Fu R, Carrino JA, et al. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373(9662):463-472. (Meta-analysis; 7 studies) DOI: 10.1016/S0140-6736(09)60172-0

50. * Downie A, Hancock M, Jenkins H, et al. How common is imaging for low back pain in primary and emergency care? Systematic review and meta-analysis of over 4 million imaging requests across 21 years. Br J Sports Med. 2020;54(11):642-651. (Meta-analysis; 45 studies) DOI: 10.1136/bjsports-2018-100087

70. * van der Gaag WH, Roelofs PD, Enthoven WT, et al. Non-steroidal anti-inflammatory drugs for acute low back pain. Cochrane Database Syst Rev. 2020;4(4):CD013581. (Cochrane review; 32 trials) DOI: 10.1002/14651858.CD013581

78. * Friedman BW, Dym AA, Davitt M, et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA. 2015;314(15):1572-1580. (Randomized controlled trial; 323 ED patients) DOI: 10.1001/jama.2015.13043

86. * Ashbrook J, Rogdakis N, Callaghan MJ, et al. The therapeutic management of back pain with and without sciatica in the emergency department: a systematic review. Physiotherapy. 2020;109:13-32. (Systematic review; 26 articles) DOI: 10.1016/j.physio.2020.07.005

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Keywords: herniation, compression, epidural, hematoma, abscess, myelitis, sciatica, immunocompromise, cauda equina, stenosis, skip lesion, opioid, NSAID