Acute Back Pain – How To Recognize When It Is An Acute Emergency – From Emergency Medicine Cases #26

I’m reviewing this episode of Emergency Medicine Cases because yesterday on the internet I read about a back pain case that went undiagnosed in an urgent care center and lead to paralysis. And it is a reminder that every case of acute back pain [whether seen in the office, the urgent care center, or the emergency department] is potentially life threatening or life changing – even if the patient has a long history of chronic back pain.

This is the outstanding podcast Episode 26: Low Back Pain Emergencies [Link is to the show notes and to the podcast] from Emergency Medicine Cases, September 12, 2012

Here is a direct link to the Episode 26 Podcast which is 2:28:33 but worth every minute.

Here are some excerpts from the show notes:

Written summary and blog post by Claire Heslop, Edited by Anton Helman September 2012


Main categories of patients with acute back pain:

  • nonspecific lumbosacral pain/strain
  • radicular pain or sciatica
  • emergent pathologies.

The 5 emergent pathologies are:

  1. infection such as osteomyelitis, or spinal epidural abscess,
  2. fracture (trauma or pathologic),
  3. disk herniation & cord compression,
  4. cancer in spine causing cord compression,
  5. vascular – leaking/ruptured AAA, retroperitoneal bleed, and spinal epidural hematoma.

Red flags for Low Back Pain Emergencies

  1. Age 60,
  2. Symptoms or history of cancer,
  3. Immunodeficiency (including diabetes, IVDU), previous spinal interventions, or recent infections,
  4. Pain not resovled by analgesia,
  5. History of trauma or coagulopathy,
  6. Cauda equina/cord compression symptoms (bowel, bladder or erectile dysfunction, saddle paresthesia, progressive bilateral leg weakness)

Pearls: *Constant, unrelenting, severe pain, especially if it is worse lying down is a red flag for infection or cancer.* Discogenic pain is worse with flexion, and pain from spondylolysis is worse with extension

Update 2018: While positive responses to “red flag’ questions for low back pain (e.g. bowel or bladder incontinence, history of cancer, trauma, fever, IV drug use etc) prompt further investigation, negative responses are not sufficient to rule out serious pathology.  Though conclusions were based on a large retrospective review, the authors present data recommending caution when using “red flag” questions  as screening tools. Abstract


A challenge in the ED? [Personal Note from Tom: But also a challenge to the primary care office physician and also to the urgent care physician.]

  • Upwards of 90% of low back pain presentations in the ED are due to benign causes. However there are several important life/limb- threatening diagnoses we must consider in the low back pain patient, and most of these diagnoses are easy to miss. Furthermore, lumbosacral sprain is often associated with significant morbidity, and ED docs should provide specific education and evidence based treatments.


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