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EMERGENCY MEDICINE PRACTICE

A N E V I D E N C E - B A S E D A P P ROAC H T O E M E RG E N C Y M E D I C I N E

February 2000

Back Pain: Cost-Effective


Strategies For Distinguishing
Between Benign And
Life-Threatening Causes

Volume 2, Number 2
Authors

EW emergency physicians can work an entire shift without seeing at


least one patient with back pain. Yet, the mere glimpse of this chief
complaint on the chart fills many emergency physicians with dread.
Imagine this scenario.
A busy shift, a full rack. The eager emergency physician reaches for
the next chart. Bad lucka back pain case. With growing trepidation, the
physicians eyes leap to the allergies field; the patient is allergic to
ibuprofen, Toradol, and all nonsteroidals. The anxiety heightens as he
scans the previous visit fieldoh no, the second visit in two weeks! He
cautiously glances to see if anyone is watching, then surreptitiously
places the chart back in the rack and reaches for the next.
What inspires this visceral fear? Is it anticipation of another
argument over narcotics? Is it that patients with back pain never
have anything bad, so they dont need to be in the ED? Alternatively,
are we fatalists, believing theres little hope for a curewhich makes
us feel inadequate, or perhaps fearful that the patient will view us
as inadequate?
No matter the reason, the pandemic of back pain is an inescapable
reality in the ED. And despite the occasional drug seeker who bemoans
his back in an attempt to secure narcotics, each year millions of Americans suffer genuine agony from back complaints. Some present to the ED
with life-threatening conditions. The emergency physician needs to
approach back pain in a manner that will reduce suffering, minimize the
cost and evaluation time for the patient, and yet not miss serious disease.
Disclaimer: The opinions and assertions contained herein are the private views of the authors
and should not be construed as official or as reflecting the views of the Department of Army or
the Department of Defense.

Editor-in-Chief
Stephen A. Colucciello, MD, FACEP,
Director of Clinical Services, Department of Emergency
Medicine, Carolinas Medical
Center, Charlotte, NC; Assistant
Clinical Professor, Department of
Emergency Med-icine, University
of North Carolina at Chapel Hill,
Chapel Hill, NC.

Associate Editor
Andy Jagoda, MD, FACEP, Associate
Professor of Emergency
Medicine, Mount Sinai School of
Medicine, New York, NY.

Editorial Board
Judith C. Brillman, MD, Residency
Director, Associate Professor,
Department of Emergency

Medicine, The University of


New Mexico Health Sciences
Center School of Medicine,
Albuquerque, NM.
W. Richard Bukata, MD, Assistant
Clinical Professor, Emergency
Medicine, Los Angeles County/
USC Medical Center, Los Angeles,
CA; Medical Director, Emergency
Department, San Gabriel
Valley Medical Center, San
Gabriel, CA.
Francis M. Fesmire, MD, FACEP,
Director, Chest PainStroke
Center, Erlanger Medical Center;
Assistant Professor of Medicine,
UT College of Medicine,
Chattanooga, TN.
Michael J. Gerardi, MD, FACEP,
Clinical Assistant Professor,
Medicine, University of Medicine
and Dentistry of New Jersey;
Director, Pediatric Emergency
Medicine, Childrens Medical

Center, Atlantic Health System;


Chair, Pediatric Emergency
Medicine Committee, ACEP.
Michael A. Gibbs, MD, FACEP,
Clinical Instructor, University of
North Carolina at Chapel Hill;
Medical Director, MedCenter Air,
Department of Emergency
Medicine, Carolinas Medical
Center, Charlotte, NC.
Gregory L. Henry, MD, FACEP, CEO,
Medical Practice Risk Assessment,
Inc., Ann Arbor, MI; Clinical
Professor, Section of Emergency
Services, Department of Surgery,
University of Michigan Medical
School, Ann Arbor, MI; President,
American Physicians Assurance
Society, Ltd., Bridgetown,
Barbados, West Indies; Past
President, ACEP.
Jerome R. Hoffman, MA, MD, FACEP,
Professor of Medicine/
Emergency Medicine, UCLA

David Della-Giustina, MD, FACEP


Major, United States Army; Adjunct Assistant Professor
of Emergency and Military Medicine; Uniformed
Services University of the Health Sciences; Director,
Madigan-University of Washington Affiliated
Emergency Medicine Residency, Madigan Army
Medical Center, Fort Lewis, WA.
Bradford A. Kilcline, MD
Captain, United States Army; Resident, MadiganUniversity of Washington Affiliated Emergency
Medicine Residency, Madigan Army Medical Center,
Fort Lewis, WA.
Mark Denny, MD
Captain, United States Army; Resident, Transitional
Year Program, Madigan Army Medical Center, Fort
Lewis, WA.
Peer Reviewer
Andy Jagoda, MD, FACEP
Associate Professor of Emergency Medicine, Mount
Sinai School of Medicine, New York, NY.
CME Objectives
Upon completing this article, you should be able to:
1. identify the red flags of back pain that indicate
serious disease;
2. describe the evaluation of the high-risk patients
with back pain, such as children and patients with
a history of cancer;
3. discuss the various treatment regimens for the
patient with lumbosacral strain and sciatica; and
4. describe the treatment and evaluation plan
for the patient with suspected epidural
compression syndrome.
Date of original release: February 1, 2000.
Date of most recent review: January 26, 2000.
See Physician CME Information on back page.

School of Medicine; Attending


Physician, UCLA Emergency
Medicine Center;
Co-Director, The Doctoring
Program, UCLA School of
Medicine, Los Angeles, CA.
John A. Marx, MD, Chair and Chief,
Department of Emergency
Medicine, Carolinas Medical
Center, Charlotte, NC; Clinical
Professor, Department of
Emergency Medicine, University
of North Carolina at Chapel Hill,
Chapel Hill, NC.
Michael S. Radeos, MD, FACEP,
Attending Physician in
Emergency Medicine, Lincoln
Hospital, Bronx, NY; Research
Fellow in Emergency Medicine,
Massachusetts General Hospital,
Boston, MA; Research Fellow in
Respiratory Epidemiology,
Channing Lab, Boston, MA.
Steven G. Rothrock, MD, FACEP,

FAAP, Assistant Professor of


Emergency Medicine, University
of Florida; Orlando Regional
Medical Center, Orlando, FL.
Alfred Sacchetti, MD, FACEP,
Research Director, Our Lady of
Lourdes Medical Center, Camden,
NJ; Assistant Clinical Professor
of Emergency Medicine,
Thomas Jefferson University,
Philadelphia, PA.
Corey M. Slovis, MD, FACP, FACEP,
Department of Emergency
Medicine, Vanderbilt University
Hospital, Nashville, TN.
Mark Smith, MD, Chairman,
Department of Emergency
Medicine, Washington Hospital
Center, Washington, DC.
Thomas E. Terndrup, MD, Professor
and Chair, Department of
Emergency Medicine, University
of Alabama at Birmingham,
Birmingham, AL.

United States for diagnosing and treating low back


pain approached $23.5 billion.4 When one adds indirect
costs such as compensation, legal fees, and lost
productivity, the cost in 1990 exceeded $50 billion.4

Studies show that emergency physicians frequently


order unnecessary diagnostic tests, prescribe unnecessary bedrest, and over-refer to specialists, when faced
with patients with low back pain. 1
This article will review the evaluation and treatment of back pain as it presents to the ED. A major
focus of this article is the red flags of back pain.
These aspects of the history and physical examination
suggest serious etiologies. By concentrating on the red
flags, the emergency physician can rapidly evaluate
and treat back pain without overlooking grave disease.

ED Evaluation: Using The Red Flags Approach


In the ED, the evaluation of patients with low back
pain must identify red flags in the history and physical exam. (See Table 1.) Specifically, the emergency
physician must be able to recognize life threats such as
ruptured abdominal aortic aneurysm (AAA), as well as
other serious pathology such as epidural compression
syndromes (spinal cord, cauda equina, conus
medullaris), spinal fracture, infection, and malignancy.
While a search for red flags and directed testing is
the most efficient known approach to the complaint of
acute low back pain, it has its limitations. One major
review found that the diagnostic accuracy of individual
items of history taking, physical examination, and
erythrocyte sedimentation rate are poor for predicting
radiculopathy, vertebral neoplasms, and ankylosing
spondylitis. 5 However, the review noted that the
combined history and the erythrocyte sedimentation
rate had relatively high diagnostic accuracy in vertebral cancer. Getting out of bed at night and reduced
lateral mobility were moderately accurate in detecting
ankylosing spondylitis.
Other studies confirm the fact that a combination of
historical factors suggests serious disease. In one study,
the highest combination of sensitivity (.87) and
specificity (.50) for a serious etiology of back disease
occurred with any combination of: unable to sleep,
awakened and unable to fall back to sleep, medication
required to sleep, and pain worsened by walking.6

Epidemiology
Back pain has an annual incidence of 5% in adults and
affects up to 90% of the general population at some
time in their lives.2 It is second only to upper respiratory illness as a reason for primary care office visits. 3
Patients may come to the ED because the symptoms
either occur or worsen when primary care appointments are unavailable, or because the patient has no
primary care physician. In 1990, the annual cost in the

Table 1. Red Flags In Patients With Back Pain.


Red Flags In The History
Red Flag
Age less than 18

Concern
Spondylolysis, spondylolisthesis,
discitis, spinal infection, tumor,
developmental disorders
Age greater than 50
Malignancy, fracture, AAA
Trauma
Fracture
Chronic steroid use
Fracture
History of cancer
Malignancy (metastases)
Fever, chills, night sweats
Infection, malignancy
Weight loss
Malignancy, infection
Injection drug use
Infection
Immunocompromise
Infection
Night pain
Malignancy, infection,
ankylosing spondylitis
Unrelenting pain
Malignancy, infection
Incontinence
Epidural compression syndrome
Saddle anesthesia
Epidural compression syndrome
Bilateral neurologic deficit Epidural compression syndrome
Unilateral neurologic
Herniated disc
deficit

The Red Flags In The History


Age
Is the patient younger than 18 years or older than 50
years? In both the old and the young, cancer is a more
common etiology for back pain. In children, lumbosacral strain is rare, with the most common cause of back
pain in adolescent athletes being spondylolysis or
spondylolisthesis.7 Spondylolysis is a defect between
superior articular process and the lamina of the
vertebral body. When this is bilateral, the involved
vertebra may slip forward (spondylolisthesis).
In the older patient, the emergency physician
should always consider AAA as the etiology for the
symptoms. In one series, back pain alone or in combination with abdominal pain was present in 53% of
those with ruptured AAA and in 63% of patients
requiring surgery for AAA.8

Red Flags In The Physical Examination


Red Flag
Fever
Anal sphincter laxity
Saddle anesthesia
Motor weakness
Absent or
diminished reflex
Positive SLR test
Positive crossed SLR test
Bone tenderness
Positive Babinskis sign

Concern
Infection, malignancy
Epidural compression syndrome
Epidural compression syndrome
Epidural compression syndrome,
herniated disc
Epidural compression syndrome,
herniated disc
Herniated disc
Herniated disc
Fracture, infection
Upper motor neuron disorder,
spinal cord compression

Emergency Medicine Practice

Duration And Acuity


Sudden-onset pain is compatible with AAA and renal
colic. While mechanical low back pain may also be
acute, most patients with lumbago complain of
progressive symptoms. The majority of patients with

February 2000

Moreover, a history of injection drug use or of an


immunocompromised state such as diabetes, organ
transplant, or HIV places the patient at an increased
risk for vertebral osteomyelitis or epidural abscess.12,14

lumbosacral sprain (LSS) will resolve or have significant improvement in their symptoms within six
weeks.9,10 Pain that lasts greater than six weeks suggests infection or malignancy.11-13 Moreover, those with
symptoms of more than six weeks duration are less
likely to respond to usual conservative management.

The Red Flags In The Physical Exam


In a similar manner, the physical examination has its
own red flags. The general appearance of the patient is
helpful. Patients with LSS generally lie flat and still, as
moving, sitting, or standing worsens their pain. In
contrast, the writhing patient may have a spinal
infection or renal colic.13,15

Character Of Pain
Discomfort due to LSS is usually well-localized to the
back and upper buttocks. Pain that radiates into the leg
or foot indicates lumbar or sacral nerve root compression and may require further diagnostic studies,
usually on an outpatient basis. Pain radiating to the
groin can occur with both renal colic and AAA. It is
classically taught that the pain of malignancy or
infection does not improve with lying flat and resting,
or is worse at night. Likewise, unrelenting pain despite
adequate treatment and analgesics raises concern for
serious disease.

Vital Signs
Fever in the patient with back pain is concerning
and signals potential infection. However, it is
variably sensitive, ranging from 16% to 83%. The
presence of fever depends upon the location of
infection and the specific pathogen involved.12,14,16,17
Hypotension in the elderly patient with back pain
may presage aortic rupture.

Location Of Pain
While no well-designed studies address this issue, case
series and textbook lore suggest the location of the
pain will narrow the differential diagnosis. Pain
confined to the mid and upper back may be related to
chest pathology, such as thoracic dissection, myocardial ischemia, and pulmonary embolism. Abdominal
disorders such as cholecystitis, pancreatitis, and peptic
ulcer disease are thought to radiate more to the midback. Pelvic pathology produces pain in either the
lower abdomen, lower back, or both.

An abdominal exam is especially important when


evaluating low back pain in the elderly. Specifically,
one palpates for a pulsatile mass, auscultates for
bruits, and evaluates femoral pulses. This said, physical examination alone is insensitive for AAA. 18 Nearly
half of all patients with AAA do not have a palpable
mass, 19 and one study suggests that neither bruits nor
absent femoral pulses have any predictive value.20

Associated Symptoms

The Back

Constitutional symptoms such as fever, chills, night


sweats, and unexplained weight loss suggest either
malignancy and infection.11,12,14 Associated symptoms
outside of the musculoskeletal system are also important to elicit. Specifically, urinary, pulmonary, or
gastrointestinal complaints point to diagnoses such as
pyelonephritis, pneumonia, pancreatitis, or cholelithiasis. Most importantly, inquire about neurologic
complaints. Target questions toward any new incontinence (bowel or bladder), erectile dysfunction, lowerextremity weakness or numbness, and saddle anesthesia. Patients with compression of the distal portion of
the spinal cord (the conus medullaris) or the nerve
roots in the spinal canal (cauda equina) may complain
of acute urinary retention. A neurologic complaint
should inspire a scrupulous neurologic examination in
the ED to determine the presence of cord compression
or cauda equina syndrome.

The back exam begins with inspection. Specifically,


look for erythema, contusions, and previous surgical
scars. Examine the alignment of the back and determine the range of motion. Patients with ankylosing
spondylitis may have loss of the normal lumbar
lordosis and marked limitation in motion of the lumbar
spine. Remember, however, that most forward flexion
takes place at the hips and not necessarily in the
lumbar spine. Next, palpate the back with specific
attention to point tenderness. Then, percuss each
vertebral body and note specific locations of tenderness. Percussion tenderness of the vertebral bodies is
common with fractures and infection.15,17,21,22 This localization of pain guides the interpretation of radiographs.

Abdominal Examination

Neurologic Examination
An adequate neurologic exam is crucial, as it allows
the emergency physician to identify potentially
catastrophic disease. The exam begins with a sensory
exam, which can adequately be accomplished with
light touch and pinprick. If any deficit is noted, formal
testing involving position sense, sharp/dull, as well as
vibratory sensation may be helpful. An understanding
of the sensory dermatomes (or a copy of the AHCPR
Tests For Low Back Pain on page 13) provides an
important anatomic reference for sensory loss. A

Past Medical History


A history of major trauma (and even minor trauma in
the elderly) can be associated with vertebral fracture.
Even strenuous lifting can cause fracture in the
osteoporotic elderly. A history of cancer is a red flag for
potential pathologic fracture from vertebral metastases
or tumor involvement of the spinal canal or cord.

February 2000

Emergency Medicine Practice

sciatica should experience symptoms with fewer


degrees of elevation.25

standard hospital pager set on buzz mode is a


convenient high-tech substitute for a tuning fork (if
you dont mind rubbing your beeper on someones
feet). Saddle anesthesia refers to a common finding
in cauda equina syndrome that presents as decreased
sensation over the buttocks, perineum, and proximal
medial thighs.
The muscle groups of the lower extremities are
individually tested against adequate resistance.
Having the patient walk on their toes and heels is an
excellent way to determine strength of the involved
muscles. Testing of the patellar (L2-L4 nerve roots) and
Achilles (S1 nerve root) reflexes should follow.
Impingement of the L5 nerve root does not produce a
reflex abnormality (as theres no readily testable reflex
for L5). However, there will be a sensory deficit in the
L5 dermatome as well as weakness of the extensor
hallucis longus (great toe dorsiflexion).
Babinskis sign is an abnormal reflex that appears
when upper motor neuron innervation through the
corticospinal tract is lost, as may occur with spinal
cord compression. A positive Babinskis sign involves
extension of the great toe and abduction (spreading
apart) of the other toes with plantar stimulation, rather
than the normal flexion response. 23
The straight leg raise (SLR) test is helpful in
identifying patients with nerve root compression by a
herniated intervertebral disc, also termed a herniated
nucleus pulposis (HNP). To perform this test, lie the
patient supine then passively raise the straight leg
anteriorly from 0 to 70 degrees. A positive test produces radicular pain below the level of the knee, in a
dermatomal distribution. Isolated back pain triggered by
this maneuver does not constitute a positive test. Radicular
pain or sciatica worsens with foot dorsiflexion
(Lasegues sign) and abates by decreasing the leg
elevation. A positive test result is approximately 80%
sensitive for herniated disc.2,24
Radicular pain down the symptomatic leg
when elevating the asymptomatic leg is a positive
crossed straight leg test. This finding is highly specific,
though insensitive, for herniated disc.2,24 An important
point regarding the straight leg raise test is that it
can be easily and stealthily performed while the
patient is seated, using a similar leg extension and
foot dorsiflexion.
Many conditions other than nerve irritation can
cause a positive straight leg raise test, including
myogenic pain, ischial bursitis, annular tear, and
hamstring tightness. One test that may distinguish
true sciatica is the sciatic stretch test. This maneuver
can remove hamstring irritation as the cause of
symptoms. In this test, the examiner raises the lower
extremity with the knee extended until the patient
experiences the leg symptoms. The physician then
lowers the leg several degrees below the point of pain
and applies popliteal compression. Compression of
the popliteal fossa will tether the sciatic nerve. When
the leg is elevated a second time, the patient with

Emergency Medicine Practice

Rectal Examination
The rectal examination will evaluate for rectal tone and
sensation, prostatic and rectal masses, and to rule out
peri-rectal abscess as the etiology for the pain. 26 A
rectal exam is not mandatory for every patient who
complains of back pain (although its routine use may
decrease ED visits for bcak pain). However, it should
be performed in all patients with neurologic complaints or deficits. Poor or absent rectal tone in the
presence of saddle anesthesia indicates an epidural
compression syndrome, most commonly a cauda
equina syndrome.

Pelvic Examination
Numerous reports and clinical experience show that
pelvic pathology can produce low back pain. However,
the evidence-based literature is mute on the indications
for pelvic examination in women with low back pain.

Tests For Non-Organic Pain


In 1980, Waddell wrote an important paper describing
five physical signs associated with non-organic back
pain. He proposed that most patients with proven
organic back pain had only one or none of these
criteria, while patients with three or more signs were
likely to have non-organic disease.27 These signs have
been wryly termed yellow flags.
Since that time, Waddells criteria have been used
(some say abused) by physicians in the evaluation of
low back pain. (See Table 2 on page 5.) Cynics claim
that patients who meet Waddells criteria are malingerers searching for drugs or disability checks. Others
believe that patients who display these findings do so
unconsciously in an attempt to communicate their
pain. One author suggested the following caveats
when using Waddells criteria:
1. Because an increase in signs is associated with age,
they are not recommended for use in the elderly.
2. Behavioral signs can occur with organic findings.
The presence of these signs does not contradict
organic findings.
3. Isolated behavioral signs are not clinically significant. A cut-off of three or more suggests nonorganic pain. 28
Two additional tests are often employed to
determine non-organic diseasethe Hoover and the
reverse sciatic tension test. 25
To perform the Hoover test, the examiner places his
or her hand under the heel of one foot and asks the
patient to raise the opposite leg. If the patient genuinely
tries to raise the leg the examiner will feel pressure
applied to their hand. In a patient who is not sincere in
their effort, there will be no contralateral pressure to
the examining hand.
The reverse sciatic tension test may be useful in the

February 2000

Non-spinal Conditions

patient with a positive SLR test. This maneuver is


performed by plantar flexing rather than dorsiflexing
the foot during the straight leg raise; if this results in
increased complaints of pain, the patient is not organic.

Non-spinal causes of back pain tend to be most lethal.


Certainly AAA tops this list. It is the first diagnosis to
rule out by history, physical, or imaging studies in the
older patient with back pain. Some non-spinal infections cause back pain, such as endocarditis and psoas
abscess. More common and less serious causes of low
back pain involve renal conditions such as pyelonephritis and renal colic, as well as abdominal and
pelvic pathology.

Differential Diagnosis Of Low Back Pain


The possible causes of low back pain are legion. (See
Table 3.) It is helpful for the emergency physician to
consider the worst first, despite the fact that most
patients will have a benign cause. Low back pain in the
elderly has a much wider range of possible causes than
in younger patients. Serious geriatric conditions
include certain malignancies, polymyalgia rheumatica,
and aortic aneurysm. Many other pathologies, such as
Pagets disease, Parkinson disease, and osteoporosis
with compression fracture, occur almost exclusively in
older adults.29
While malignancy is rarely an acute emergency,
with the exception of epidural compression syndromes, it is an important diagnosable cause of back
pain. One study of 1,975 outpatients with low back
pain found that cancer could be excluded if none
of the following was present: age > 50, history of
cancer, unexplained weight loss, and failure of
conservative therapy.11

Spinal Causes Of Back Pain


Table 4 (on page 6) outlines the spinal causes of back
pain that are explained in the following sections.

Epidural Compression Syndromes


Epidural compression is a true emergency and should
be ruled out by history and physical examination in
every patient with back pain. While a complete
epidural compression syndrome with paraplegia is
obvious, mild or early compression can be difficult to
discern. However, the consequences of misdiagnosis

Table 3. How The Emergency Physician Considers


The Differential Diagnosis Of Back Pain.
Immediate Threats To Life
AAA
Pulmonary embolism
(upper and mid-back
generally
not lower back)
Thoracic aortic dissection
(upper and mid-back
generally not lower back)
Myocardial infarction
(upper and mid-back
generally
not lower back)

Table 2. The Waddell Criteria.


Tenderness
Superficial (significant pain to light touch or pinch)
Non-anatomic (tender to palpation over LS, Pelvis, and
TS)
Simulation
Axial loading (low back pain with light pressure to skull
while standing)
Rotation (increase of low back pain with passive rotation
of the shoulders and pelvis in the same plane, in the
standing position)

Immediate Threats To
Spinal Cord
Epidural mass effect
Tumor
Hematoma
Abscess
Disc herniation (rarely
causes acute threat in
lumbar area)

Distraction
SLR: Inconsistent findings in sitting vs. supine straight leg
raising
Regional Disturbance
Weakness: Generalized giving way or cog-wheeling
resistance when testing strength in the lower extremities
Sensory: Stocking sensory loss, non-dermatomal

Urgent Threats
Cardiac
Endocarditis
Renal
Pyelonephritis
Infected stone
Renal artery dissection
Abdominal
Perforated ulcer
Vertebral
Unstable fracture

Overreaction (most important Waddell criteria)


Disproportionate pain response
Bracing: Both limbs supporting weight while seated
Clutching, grasping affected area for more than three
seconds
Dramatic grimacing
Sighing with shoulders rising and falling
Annotations adapted from: Polatin PB, Cox B, Gatchel RJ, et al. A
prospective study of Waddell signs in patients with chronic low back
pain: When they may not be predictive. Spine 1997;22:1618-1621.

February 2000

Gynecologic
Abruptio placenta
Serious But Not Acutely
Dangerous
Vertebral
Osteomyelitis
Potts Disease (tuberculosis of spine)
Tumor
Stable fracture
Spondylolisthesis
Disc
Herniated Disc
Discitis
Rheumatologic
Ankylosing spondylitis
Abdominal
Pancreatitis
Gynecologic
PID
Less Serious (But May
Represent A Pain
Emergency)
Renal
Ureteral Colic
Gynecologic conditions
Pregnancy
Endometriosis
Ovarian conditions
Dysmenorrhea
Musculoskeletal
Lumbosacral strain
Varicella Zoster

Emergency Medicine Practice

tumors, epidural abscess, and trauma. Patients on


warfarin, or those with coagulopathy, may develop
spontaneous epidural hematomas or following trauma,
including iatrogenic injury such as a lumbar puncture.

can be catastrophic, as most cases are progressive and


often irreversible. Diagnosing the early or subtle cases
is made more difficult because MRI, the gold standard
test in making the diagnosis, can be difficult, if not
impossible, to obtain emergently.
Epidural compression syndrome is a collective
term encompassing spinal cord compression, cauda
equina syndrome, and conus medullaris syndrome.
Cauda equina syndrome differs from spinal cord
compression in that it occurs below the level of the
cord and involves the spinal nerve roots of the cauda
equina. Typically, patients present with a classic
syndrome of urinary retention with resultant incontinence, saddle anesthesia, anal sphincter laxity, and
associated bilateral weakness and sensory deficits in
the lower extremities. In the early stages, conus
medullaris syndrome commonly presents with bladder
dysfunction and possibly fecal incontinence, with later
development of lower lumbar and sacral motor,
sensory, and reflex impairment.
There are two reasons why these syndromes are
grouped together. First, individual syndromes are
frequently indistinguishable based on the presenting
history and physical examination. For example, an
incomplete spinal cord compressive lesion at T10 may
initially present like a cauda equina syndrome. Secondly, the initial ED evaluation and management for
these syndromes is similar.

Presentation
Some patients with epidural compression may present
with a dramatic history, such as lower extremity
weakness progressing to paraplegia in a matter of
hours. Others have less sensational complaints of
slowly progressive weakness or numbness. While back
pain is frequent, it may not predominate.
The most important factors to consider are the
bilaterality of the symptoms and the involvement of
more than one spinal level. Lower extremity symptoms
and signs may be associated with bowel or bladder
incontinence and saddle anesthesia. Physical examination
usually reveals bilateral lower extremity weakness,
hyporeflexia, and abnormal sensation. Often, there is no
specific nerve root distribution as multiple spinal levels
are involved, although one should attempt to determine a
spinal level. Urinary incontinence results from bladder
spasms secondary to associated urinary retention.
Urinary retention is approximately 90% sensitive for cauda
equina syndrome, while decreased anal sphincter tone
occurs in 60-80% of cases.21 Urinary retention or a
complaint of urinary incontinence is easily evaluated by
obtaining a post-void residual through catheterization.
Any residual volume greater than 50-100 mL is cause for
concern. Alternatively, ED ultrasonography may determine post-void residual in a non-invasive manner.

Etiologies
In the younger adult population, epidural compression
usually results from a cauda equina syndrome due to a
large central disc herniation. However, other etiologies to
consider in all age groups include primary or metastatic

Management
When an emergency physician suspects an epidural

Table 4. Differential Diagnosis Of Spinal Etiologies For Back Pain.


Diagnosis
Lumbosacr al str ain (LSS)

Etiology/Findings
Ligamentous and muscular strain
History of overuse or trauma
Worse with activity, better with rest
Tenderness with lumbosacral palpation

Red Flags
None

Sciatica

Herniated disk, most commonly at L4-L5 / L5-S1


Lower extremity symptoms predominate
Dermatomal distribution, radiates to foot
Positive straight leg raise test

Yes
(Neurologic complaints)
(Neurologic deficits)

Spinal c ord compression

Large central disc herniation, tumor, trauma


Progressive weakness in both lower extremities
Mild back pain
Emergent MRI indicated

Yes
(Neurologic complaints)
(Neurologic deficits)

Cauda equina syndr ome

Similar etiology to spinal cord compression


Saddle anesthesia
Urinary retention, anal sphincter laxity
Emergent MRI indicated

Yes
(Neurologic complaints)
(Neurologic deficits)

Spinal inf ection

Prolonged symptoms (> 3 months)


Immunocompromised, IDU
S. aureus, S. epidermidis, Streptococci
urinary pathogens
ESR is sensitive screen

Yes
(Fever, night sweats)
(Weight loss)
(Unrelenting pain)

Emergency Medicine Practice

February 2000

Sciatica

compression syndrome, he or she must take quick action.


Do not wait for a confirmatory MRI to begin treatment. Begin
steroids immediately, and call a neurosurgeonthe
deficit is often progressive and potentially irreversible.
Epidural compression syndrome is one of the few
occasions when an emergency physician should obtain
a stat MRI. If MRI is not available, then CT with
myelography is the next best study.

Sciatica is defined as pain in the distribution of a


lumbar or sacral nerve root, often accompanied by
sensory or motor deficits.2 True sciatica is much less
common than LSS, affecting approximately 1% of
patients with acute low back pain.2 The typical patient
complains of mild to moderate back pain, but the key
to the diagnosis is radicular pain below the knee.
Usually, this affects only one leg and is often associated
with paresthesias, numbness, and possibly weakness
on the affected side.
The cause of sciatica is usually a herniated intervertebral disc; 95% of patients with herniated discs
present with sciatica as a chief complaint. 2 Other
etiologies to consider include foraminal stenosis, spinal
stenosis, intraspinal tumor or infection, and piriformis
syndrome. Piriformis syndrome is a lesser-known
cause of sciatica whereby trauma or injury to the
piriformis muscle results in spasm and inflammation
that may produce concomitant sciatic nerve impingement. 2,35 In one study, it accounted for 6% of patients
with chronic back pain. 36
Ninety-five percent of herniated discs occur at the
L4-L5 or L5-S1 levels, which results in compression of
the L5 or S1 nerve roots, respectively. This compression
produces a radiculopathy along the dermatomes of the
involved nerve root, as well as sensory, muscular, and
reflex changes for the involved nerve root.2 Patients
with L5 compression may have difficulty with heel
walking (and may demonstrate a foot drop), while
those with an S1 problem may not be able to walk on
their toes. Older patients have a higher incidence of
more proximal disc herniation, such as L2-L3 and L3L4.2 These patients may complain of pain in the
anterior thigh, and demonstrate sensory deficits in the
L3 or L4 dermatomes as well as quadriceps weakness
with an associated diminished patellar reflex. The
history may reveal some recent trauma; however, more
often the patient complains of mild to moderate back
pain that preceded the sciatica for a period of days to
weeks. This back pain may or may not have improved
with the appearance of the sciatica.24 The pain of a
herniated disc often worsens with Valsalva maneuvers,
coughing, and sitting.2,24
The physical examination of the patient with
sciatica reveals a stationary patient. However, a major
difference between sciatica and LSS is the physical
exam findings. Namely, the straight leg raise test and
the lower extremity neurologic exam may be abnormal
in patients with nerve root compression. Radiographic
imaging for sciatica is generally not necessary in the ED
because plain films will not demonstrate disc herniation.
However, plain radiographs may be indicated if there
are red flags for malignancy, epidural compression,
infection or fracture.2,9,11,24,37,38 If the physician is
concerned about a more serious etiology for the
sciatica, he or she may consider ordering an MRI or CT
scan rather than plain radiography. However, this

Prognosis
The prognosis of epidural compression syndrome
depends upon the patients neurological status at the
time of intervention. Specifically, for those patients
with epidural compression due to malignancy, those
who are ambulatory generally remain so. Of patients
who are paraplegic at intervention, approximately 10%
regain ambulation. 30,31

Spinal Infections
Infection is an uncommon cause of back pain that
generally occurs in immunocompromised patients
(diabetics, injection drug users [IDUs], transplant
patients, and cancer patients). These patients typically
have prolonged symptoms, and in more than half of
those with osteomyelitis, the pain has been present for
three or more months.16,17,22,32
Pain is nearly a universal complaint in spinal
infections. The pain is often insidious, and becomes
unrelenting and nocturnal. The most common spinal
infections include vertebral osteomyelitis and
epidural abscess. Staphylococcus aureus is the
predominant pathogen, although S. epidermidis,
Streptococci, and even urinary pathogens such as
E. coli or Proteus occur.12,13,15-17
The physical exam can be misleading in patients
with spinal infections. In vertebral osteomyelitis, fever
occurs in only half of patients; epidural abscess is
much more likely to produce fever.12,15-17,33 Most
patients will have vertebral body percussion tenderness, although this finding is nonspecific.
Lab testing can also be deceptive. The white blood
cell (WBC) count is elevated in fewer than 50% of
patients with spinal infection. 12,13,15-17,34 However, the
erythrocyte sedimentation rate (ESR) is a sensitive but
nonspecific screening test, elevated in greater than 95%
of patients with a normal immune system and 90% of
those with immune suppression.12,13,16,17,22
The emergency physician should order diagnostic
imaging when they suspect spinal infection. Plain films
may be useful, but a spinal MRI (the gold standard) or
CT is more sensitive and specific than radiographs.
This is especially true early in the disease process, as it
may take up to eight weeks before lytic changes
become evident on x-ray.17,32
The prognosis for spinal infection is fair, with
mortality rates ranging from less than 5% to greater
than 25%. 12,15-17,32 The outcome depends upon the nature
of the infection (osteomyelitis vs epidural abscess), the
patients immune system status, and general health.

February 2000

Continued on page 15

Emergency Medicine Practice

Clinical Pathway: Evaluation Of Patients


With Low Back Pain

Age >18 years non-pregnant acute (<4 weeks duration) low back pain and/or back-related leg symptoms, not suspected to be
renal colic?
Focused HPI:
Location of symptoms: Back, leg, both
Duration
Functional limitations
Mechanism of onset: Spontaneous or specific (trauma)
Character or description of pain: Mechanical, radicular, non-specific, increased by rest, nocturnal pain
Previous treatment and response
Neurologic history: Distribution, bowel and bladder symptoms, sexual dysfunction, weakness, numbness (including saddle),
signs/symptoms of cauda equina syndrome
Fever
Unexplained weight loss
History of malignancy
History of intravenous drug use
Mental health/psychiatric/rehabilitation problems
Prior back surgery

If >60 years old, consider AAA as first diagnosis to rule out


(Class IIa)

Physical examination options:


Inspection of posture, stance, and gait
ROM of spine, hip and lower extremity
Specific tests (straight leg raising, sitting knee extension)
Neurological screening
Abdominal exam
Rectal examination if indicated

Yes

Plain x-ray
(Class IIa)

Evidence of
fracture or
serious disease?

Yes

Appropriate treatment or consultation


(Class IIa)

Red flags for spinal fracture:


Major trauma
Minor trauma/strenuous lifting in older
or potentially osteoporotic patient
Chronic steroid use

No

No
Go to Evidence of non-spinal
medical problems causing
referred back complaints? path
on next page

Go to Red flags for tumor


path on next page

The evidenc e for recommenda tions is graded using the following scale. For complete definitions, see back page. Class I: Definitely recommended.
Definitive, excellent evidence provides support. Class II a: Acceptable and useful. Very good evidence provides support. Class II b: Acceptable and useful.
Fair-to-good evidence provides support. Class III: Not acceptable, not useful, may be harmful. Indeterminate: Continuing area of research.

This clinical pathway is intended to supplement, rather than substitute, professional judgment and may be changed depending upon a
patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2000 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants permission to reproduce this
Emergency Medicine Practice tool for institutional use.

Emergency Medicine Practice

February 2000

Clinical Pathway: Evaluation Of Patients


With Low Back Pain (continued)
Red flags for tumor:
Age >50 or < 20
History of cancer
Unexplained weight loss
Duration of pain>1 month
Persistent fever

Red flags for possible infection:


IVDA
Fever/chills
Recent bacterial infection
Immune suppression
New heart murmur

Red flags for cauda equina


syndrome:
Saddle anesthesia
Recent onset of bladder/
bowel dysfunction (check
post-void residual)
Severe or progressive
neurologic deficit in the
lower extremity
Unexplained laxity of the
anal sphincter
Major motor weakness of
quadriceps or foot drop

Yes

Appropriate treatment or consultation


(Class IIa)

Yes

Appropriate treatment or consultation


(Class IIa)

No

Yes

Consider ESR, CBC


and imaging studies
(see page 10)

Evidence of
fracture or
serious disease?

Yes

Special thanks to Dr. Andrew Asimos for this adaptation from the
AHCPR guidelines.

Go to page 10

Adapted from: Bigos S, Bowyer O, Braen, et al. Acute low back


problems in adults. Clinical Practice Guideline No. 14. AHCPR
Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy
and Research, Public Health Service, U.S. Department of Health and
Human Services. December 1994. Agency for Health Care Administration, State of Florida, in Consultation with the Medical/Surgical
Neuro-Musculo-Skeletal Guideline Committee and its Neurosurgical
Surgery Subcommitee: Universe of Florida Patients with Low Back
Pain or Injury. Medical Practice Guidelines for Practitioners Licensed
Under Chapter 458 (Medicine) or Chapter 459 (Osteopathy), Florida
Statutes, Florida Health Care Insurance Reform Act of 1993, Section
4108.02; Florida Workers Compensation Reform Act of 1993, Section
440.13(15). Endorsed October 6, 1995; amended February 2, 1996.

Neurologic deficit:
Motor and/or reflex changes
Objective sensory loss

Yes

Go to page 10

The evidenc e for recommenda tions is graded using the following


scale. For complete definitions, see back page. Class I: Definitely
recommended. Definitive, excellent evidence provides support. Class
IIa: Acceptable and useful. Very good evidence provides support. Class
IIb: Acceptable and useful. Fair-to-good evidence provides support.
Class III: Not acceptable, not useful, may be harmful. Indeterminate:
Continuing area of research.

No

Evidence of non-spinal
medical problems causing
referred back complaints?

No

No

Yes

Appropriate treatment or consultation


(Class IIa)

This clinical pathway is intended to supplement, rather than


substitute, professional judgment and may be changed
depending upon a patients individual needs. Failure to comply
with this pathway does not represent a breach of the standard
of care.

No

Provide assurance/education about back problems


Activity as tolerated
Review activity limitations
Ibuprofen or acetaminophen
Consider muscle relaxants, opioids
(Class IIb)

February 2000

Evidence of
fracture or
serious disease?

No

Consider ESR, CBC


and imaging studies
(Class IIa)
(see also page 10)

No

Yes

Copyright 2000 Pinnacle Publishing, Inc. Pinnacle


Publishing (1-800-788-1900) grants permission to
reproduce this Emergency Medicine Practice tool for
institutional use.

Emergency Medicine Practice

Clinical Pathway: Management Of Back Pain


According To Presumed Etiology
Red
flags?

No

Epidur al compression?
Saddle anesthesia
Urinary retention
Incontinence
Neurological deficit

Acute
lumbosacral strain
(Class I)

Yes

Yes

Dexamethasone (Class I)
Emergent MRI (Class I)
Consult (Class I)

No

Yes

Yes

Consistent with
infection?
No

No

Admit/consult
(Class I)
Consider antibiotics
in ED (Class IIb)

Consider other etiology


(ClassI)

Spinal imaging (plain


radiography or CT) (Class I)
ESR (Class IIa)
CBC, UA C&S (Class IIb)

Yes

Tumor?
Age > 50
Night pain, unrelenting
pain
Weight loss
Pain > 6 weeks
Fever

CT or MRI (Class I)
Plain radiography (Class IIb)
CBC, ESR, UA C&S (Class I)
Blood culture x 2 (Class IIa)

Infection?
Fever, night sweats
Night pain, unrelenting
pain
Injection drug user
Immunocompromised
Pain > 6 weeks

Consistent with
tumor?

Specialty consultation
(Class I)

No

Yes

No

Treat as lumbosacral strain;


follow up with primary care
physician at 7-10 days (Class I)

See page 11 if history of


cancer, fracture, sciatica, or
age < 18.

The evidenc e for recommenda tions is graded using the following scale. For complete definitions, see back page. Class I: Definitely recommended.
Definitive, excellent evidence provides support. Class II a: Acceptable and useful. Very good evidence provides support. Class II b: Acceptable and useful.
Fair-to-good evidence provides support. Class III: Not acceptable, not useful, may be harmful. Indeterminate: Continuing area of research.

This clinical pathway is intended to supplement, rather than substitute, professional judgment and may be changed depending upon a
patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2000 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants permission to reproduce this
Emergency Medicine Practice tool for institutional use.

Emergency Medicine Practice

10

February 2000

Clinical Pathway: Back Pain With Sciatica,


Question of Fracture, Or Age Less Than 18 Years
Yes

Sciatica?

No

Treat like HNP (Class IIa)


or Consider plain radiography to
rule out tumor, fracture, spondylolisthesis, and infection (Class IIb)

Yes

Normal?

Treat like HNP (Class IIa)


Follow up in 1-2 weeks with primary
care physician (Class IIa)

No

Reevaluate (Indeterminate)

Yes

Normal?

Yes

Treat for acute lumbosacral


strain (Class IIa)

No

No

Treat for fracture type (Class IIa)


Consult orthopedics (Class IIa)

Yes

Age less than 18 years?

Plain radiography (Class IIa)

Fracture?
History of trauma
Age > 50
Osteoporosis

Plain films (Class IIa): two-view


initially; five-view if normal
CBC, ESR, UA (Class IIb)

Consistent with
spondylolysis or
spondylolisthesis?

Yes

Treat for acute lumbosacral


strain (Class IIa)

No

Reevaluate (Indeterminate)

The evidenc e for recommenda tions is graded using the following scale. For complete definitions, see back page. Class I: Definitely recommended.
Definitive, excellent evidence provides support. Class II a: Acceptable and useful. Very good evidence provides support. Class II b: Acceptable and useful.
Fair-to-good evidence provides support. Class III: Not acceptable, not useful, may be harmful. Indeterminate: Continuing area of research.

This clinical pathway is intended to supplement, rather than substitute, professional judgment and may be changed depending upon a
patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2000 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants permission to reproduce this
Emergency Medicine Practice tool for institutional use.

February 2000

11

Emergency Medicine Practice

Clinical Pathway: Back Pain In The Cancer Patient


History of
cancer?

Yes

Group I:
New or progressive
neurologic symptoms?

Yes

Treat like epidural compression


syndrome (Class I)

No

Group II: Neurologic


symptoms, neither acute
nor progressive

Yes

Plain radiography (Class I)

No

X-rays consistent
with mets/tumor?

Group III: Back pain only

Yes

Dexamethasone
(Class I)
MRI < 24 hours
(Class I)

No

MRI 3-5 days


(Class IIb)
Close follow-up
(Class I)

Plain radiography (Class I)

X-rays consistent
with mets/tumor?

Yes

Consult (Class I)

No

Treat like lumbosacral


strain (Class I)
Follow up with primary
care physician in one week
(Class I)

The evidenc e for recommenda tions is graded using the following scale. For complete definitions, see back page. Class I: Definitely recommended.
Definitive, excellent evidence provides support. Class II a: Acceptable and useful. Very good evidence provides support. Class II b: Acceptable and useful.
Fair-to-good evidence provides support. Class III: Not acceptable, not useful, may be harmful. Indeterminate: Continuing area of research.

This clinical pathway is intended to supplement, rather than substitute, professional judgment and may be changed depending upon a
patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2000 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants permission to reproduce this
Emergency Medicine Practice tool for institutional use.

Emergency Medicine Practice

12

February 2000

AHCPR Tests For Low Back Pain


Testing for Lumbar Nerve Root Compromise
Nerve root

L4

L5

Instructions For The Straight Leg Raise Test


1.Ask the patient
to lie as straight
as possible on a
table in the
supine position.

S1

Pain

Great toe

2.With one hand


placed above
the knee of the
leg being
examined, exert
enough firm pressure to keep the knee fully extended.
Ask the patient to relax.

Heel

Numbness
3.With the other hand cupped under the heel, slowly raise
the straight limb. Tell the patient, If this bothers you, let
me know, and I will stop.
4.Monitor for any movement of the pelvis before complaints are elicited. True sciatic tension should elicit
complaints before the hamstrings are stretched enough
to move the pelvis.

Screening
exam
Reflexes

Extension of
quadriceps

Dorsiflexion
of great toe
and foot

Squat
and rise

Heel
walking

Knee jerk
diminished

None
reliable

Plantar flexion
of great toe
and foot

5.Estimate the degree of leg elevation that


elicits complaint from the patient. Then
determine the most distal area of
discomfort: back, hip, thigh, knee, or
below the knee.

Walking
on toes

6.While holding
the leg at the
limit of straight
leg raising,
dorsiflex the
ankle. Note
whether this
aggravates the
pain. Internal
rotation of the
limb can also increase the tension on the sciatic nerve
roots.

Ankle jerk
diminished

Instructions For Sitting Knee Extension Test


With the patient sitting
on a table, both hip
and knees flexed at
90, slowly extend the
knee as if evaluating
the patella or bottom
of the foot. This
maneuver stretches
nerve roots as much as
a moderate degree of
supine SLR.

Adapted from: Bigos S, Bowyer O, Braen, et al. Acute low back problems in adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642.
Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. December 1994.
Agency for Health Care Administration, State of Florida, in Consultation with the Medical/Surgical Neuro-Musculo-Skeletal Guideline Committee and
its Neurosurgical Surgery Subcommitee: Universe of Florida Patients with Low Back Pain or Injury. Medical Practice Guidelines for Practitioners
Licensed Under Chapter 458 (Medicine) or Chapter 459 (Osteopathy), Florida Statutes, Florida Health Care Insurance Reform Act of 1993, Section
4108.02; Florida Workers Compensation Reform Act of 1993, Section 440.13(15). Endorsed October 6, 1995; amended February 2, 1996.

February 2000

13

Emergency Medicine Practice

AHCPR Guideline Recommendations


For Assessment And Treatment Acute Low Back Problems in Adults
The ratings in parentheses indicate the scientific evidence supporting each recommendation according to the following scale:
A = strong research-based evidence (multiple relevant and high-quality scientific studies)
B = moderate research-based evidence (one relevant, high-quality scientific study or multiple adequate scientific studies)
C = limited research-based evidence (at least one adequate scientific study in patients with low back pain)
D = panel interpretation of evidence not meeting inclusion criteria for research-based evidence
The number of studies meeting panel review criteria is noted for each category.

History and physical exam (34 studies)

Physical treatment methods (42 studies)

Recommend:
Basic history (B).
History of cancer/infection (B).
Signs/symptoms of cauda equina syndrome (C).
History of significant trauma (C).
Psychosocial history (C).
Straight leg raising test (B).
Focused neurological exam (B).

Recommend:
Manipulation of low back during first month of symptoms (B).
Option:
Manipulations for patients with radiculopathy (C).
Manipulation for patients with symptoms >1 month (C).
Self-application of heat or cold to low back (C).
Shoe insoles (C).
Corset for prevention in occupational setting (C).

Option:
Pain drawing and visual analog scale (D).

Recommend against:
Manipulation for patients with undiagnosed neurologic
deficits (D).
Prolonged course of manipulation (D).
Traction (B).
TENS (C).
Biofeedback (C).
Shoe lifts (D).
Corset for treatment (D).

X-rays of L-S spine (18 studies)


Recommend:
When red flags for fracture present (C).
When red flags for cancer or infection present (C).
Recommend against:
Routine use in first month of symptoms in absence of red flags (B).
Routine oblique views. (B).

Injections (26 studies)

Imaging (18 studies)

Option:
Epidural steroid injections for radicular pain to avoid surgery (C).

Recommend:
CT or MRI when cauda equina, tumor, infection, or fracture strongly
suspected (C).
MRI test of choice for patients with prior back surgery (D).
Assure quality criteria for imaging tests (B).

Recommend against:
Epidural injections for back pain without radiculopathy (D).
Trigger point injections (C).
Ligamentous injections (C).
Facet joint injections (C).
Needle acupuncture (D).

Option:
Myelography or CT-myelography for preoperative planning (D).

Bed rest (4 studies)

Recommend against:
Use of imaging test before one month in absence of red flags (B).
Discography or CT-discography (C).

Option:
Bed rest of 2-4 days for severe radiculopathy (D).

Medication (23 studies)

Recommend against:
Bed rest >4 days (B).

Recommend:
Acetaminophen (C).
NSAIDs (B).

Activities and exercise (20 studies)


Recommend:
Temporary avoidance of activities that increase mechanical stress
on spine (D).
Gradual return to normal activities (B).
Low-stress aerobic exercise (C).
Conditioning exercises for trunk muscles after 2 weeks (C).
Exercise quotas (C).

Option:
Muscle relaxants (C).
Opioids, short course (C).
Recommend against:
Opioids used >2 wks (C).
Phenylbutazone (C).
Oral steroids (C).
Colchicine (B).
Antidepressants (C).

Recommend against:
Back-specific exercise machines (D).
Therapeutic stretching of back muscles (D).

Adapted from: Bigos S, Bowyer O, Braen G. et al. Acute Low Back Problems in Adults. Clinical Practice Guideline, Quick Reference Guide Number 14.
Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, AHCPR Pub.
No 95-0643. December 1994.

Emergency Medicine Practice

14

February 2000

Continued from page 7

undermine the value of the urinalysis in this situation.


In one study, 14% of patients with CT-proven ureterolithiasis had no hematuria on urine dipstick and 1 or
less RBCs per high power field on microscopy. Of the
back-pain patients without ureterolithiasis who
underwent CT, 24% had more than 5 RBCs per high
power field.41 Hematuria may be a prominent or
incidental finding in many patients with non-renal
back pain, including those with AAA. At least one
report shows an 87% incidence of hematuria in ruptured AAA (although most other reports are around
30%).42 Furthermore, the presence of gross hematuria
causes a significant delay in the diagnosis because the
physician pursues a urinary work-up.43 Still, the search
for hematuria, whether by dipstick or microscope, will
probably continue to play a role in the evaluation of
ureteral colic and acute back pain.
The urinalysis may also demonstrate signs of
infection in patients with low back pain. This includes
a positive leukocyte esterase reaction or positive
nitrate on dipstick, and leukocytosis and bacteria or
both on microscopy. In young, otherwise healthy
women, pyelonephritis can cause back pain; it is very
rare in men who do not have prostatic hypertrophy or
a prior history of renal disease. Women with pyelonephritis usually complain of back pain in combination
with fever and nausea, vomiting, or both. Pyuria is
routine. The combination of fever plus pyuria has a
98% positive predictive value for pyelonephritis in
adult women. In the afebrile woman with back pain
and pyuria, the emergency physician should consider
competing diagnoses in addition to pyelonephritis.44
Based on the limited data, a urinalysis may be helpful
in women or in elderly patients of either sex who
present with a history of recent fever, nausea or
vomiting, or with physical findings of elevated
temperature or flank tenderness.
Obtaining a UA is also an important consideration
in patients with chronic pain suspected of spinal
infection. A number of studies demonstrate that the
most common primary source of infection in vertebral
osteomyelitis is the genitourinary system, probably
through hematogenous spread.12,13,16,17,22,34 A urinalysis
and urine culture may be helpful in identifying a
specific pathogen and ultimately tailoring antibiotics.

approach has not been evaluated for cost-effectiveness


and utility.

Acute Lumbosacral Strain


The majority of patients presenting with low back pain
suffer from a benign condition commonly called
lumbosacral strain (LSS). This is an injury, possibly
with subsequent inflammation, of the lumbosacral
ligaments and musculature. The history and physical
exam are usually devoid of red flags. Often, the
patient relates a history of preceding trauma, such as
heavy lifting; however, this is not universal, and many
patients cannot identify a specific preceding injury or
episode of overuse. The pain of LSS is well localized to
the lower back and upper buttocks, and typically
worsens with activity and improves with rest. Physical
examination reveals a patient lying supine and still,
trying not to move. Often, tenderness over the paravertebral musculature is present, although exact reproduction of the pain is atypical. As discussed later in this
article, no further diagnostic tests are required, and
these patients generally have an excellent prognosis
with conservative therapy.2,9
Back pain is price man paid for the hubris
of walking erect.Anonymous

Diagnostic Studies
Laboratory
Most patients with low back pain do not need laboratory testing in the ED. In selected patients, a few tests
may be helpful. These include a complete blood count
(CBC), a urinalysis (UA), and an erythrocyte sedimentation rate (ESR). These studies are indicated when the
patient has red flags for infection or tumor, or when a
child presents with atraumatic back pain.

Blood Tests
The ESR is especially sensitive to spinal
infection.12,13,15-17,22,34,39 In addition to non-spinal
infections (such as endocarditis), the ESR may also
be elevated in the setting of neoplasm and rheumatologic disease, such as ankylosing spondylitis.11,40
While the CBC remains a reflex response to fever
(despite the best efforts of Emergency Medicine Practice),
it falls short in its performance in patients with spinal
infections. In most cases, it is falsely normal despite
significant disease.

Radiographic Studies
Plain Radiography
Plain spinal radiographs are indicated whenever there is
history of significant trauma, suspicion of fracture,
infection, tumor, or neurologic deficit. Older patients and
those on chronic steroids may require x-rays after even
minor trauma, especially if they demonstrate percussion
tenderness of the vertebrae. Plain films are limited in
their ability to detect infection, tumor, or herniated disc.
It is unnecessary to obtain plain films in patients with
only back pain and no red flags. Because symptoms will
resolve in approximately 90% of these patients within 4

Urinalysis
The urinalysis may be useful in a variety of patients
with back pain, both acute and chronic. In the patient
with acute severe pain in the back or flank, a urinalysis
is routinethe assumption being that the presence or
absence of hematuria should direct evaluation of
possible renal colic. However, recent data tends to

February 2000

15

Emergency Medicine Practice

to 6 weeks, a diagnostic work-up only adds cost and


radiation exposure, without any impact on the case
management. Plain films cost between $170 and $200 per
study and yield nearly 2,000 times the gonadal radiation
as chest x-ray. (A chilling thought.)
When the decision is made to obtain plain radiographs, only AP and lateral views of the lumbar spine
should be obtained, as the oblique and cone-down
views typically add little information. 2,37,38 Also, the
two-view lumbosacral series exposes the gonads to
only half of the radiation that the patient would
otherwise be exposed to in the standard five-view
series. 2,38 Because the two-view series costs about $120
less than the five-view series, obtain the two-view
series initially and review it before obtaining any
additional views. Complete a five-view series if there
is an abnormality on the initial views. A five-view
series is also useful in patients under age 18 if spondylolysis or spondylolisthesis is suspected but not
identified on the initial views.

spinal infection, tumor, herniated disc, spinal hematoma, and acute neurological deterioration, because
it clearly delineates spinal cord, canal, and disc
anatomy.12,32,34,46,47 Furthermore, MRI does not use
ionizing radiation. For this reason, it is the imaging
study of choice in pregnant women.47

Limitations Of MRIs
Limitations include availability, cost, time, claustrophobia, contraindications, and over-sensitivity. MRI is
not available emergently, or at all, in many smaller
hospitals. The average charge for an MRI with contrast
of the lumbosacral spine is approximately $1,600,
whereas a non-contrast CT scan of the same area costs
$650 (plus a myelography fee, if used). Also, MRI
requires a significant amount of time depending on the
number of spinal segments scanned. This may be
extremely uncomfortable for the claustrophobic patient
and frankly dangerous for the patient who is deteriorating rapidly. MRI is contraindicated in individuals
with pacemakers, intracardiac wires, some intracranial
aneurysm clips, and some types of heart valves.
Finally, MRI is overly sensitive when used indiscriminately. In one study, in patients with no history or
symptoms of back pain, MRI demonstrated disc
herniation or bulging in 22% of patients younger than
60 years old and in 36% of those over age 60.48 Most
authorities do not consider isolated foot drop secondary to a presumed herniated disc to be an indication
for an acute MRI, since few surgeons would acutely
operate on such a patient.

MRI
Any patient with signs or symptoms suggestive of
epidural compression warrants an emergent MRI. The
MRI may initially be limited to the lumbosacral spine
in patients with suspected cauda equina syndrome
secondary to disc herniation, especially if back pain is
localized to the lower lumbar spine. However, the
entire spine (cervical, thoracic, lumbar, and sacral)
should be evaluated in patients with suspected spinal
cord compression for two reasons. First, there is the
risk of localizing the physical findings to the wrong
spinal level and potentially missing a more proximal
lesion on the MRI. 45,46 Second, there is a 10% chance of
asymptomatic distant metastases in metastatic cord
compression, and their discovery may alter the
therapeutic plan.30 In addition to diagnosing epidural
compressive lesions, MRI is the gold standard test for

CT Scan
The primary indication for CT scanning in the setting
of low back pain is fracture evaluation, since CT is
superior to MRI in evaluating bony architecture.
However, when used in conjunction with myelography,
CT scanning is as effective as MRI in diagnosing

Pearls And Pitfalls In Patients With Low Back Pain


in the patient with a suspected spinal infection, as they
frequently are positive.
7. Back pain in an injection drug user is an infection
(osteomyelitis, endocarditis, or epidural abscess) until
proven otherwise.
8. Patients with suspected herniated disc do not require
imaging with MRI unless they fail to improve in 4-6
weeks; thus, theres no need to order this study out of
the ED.
9. Only 5-10% of all patients with sciatica ultimately
require surgery, so you do not need to refer them to a
spine surgeon from the ED. Let their primary care
physician take care of specialty referral.
10. All patients with suspected epidural compression
syndromes require treatment with steroids before
obtaining confirming diagnostic tests.

1. Always consider a rupturing abdominal aortic


aneurysm in patients over age 55 with acute low
back pain.
2. Patients with lumbosacral strain or sciatica should
continue their routine activities as tolerated rather than
undergoing bedrest.
3. In the patient with low back pain and no red flags,
theres no need to obtain any diagnostic tests.
4. Children with back pain have a higher incidence of
serious diagnosable etiologies for their symptoms and
require diagnostic testing at the initial evaluation to
determine the etiology.
5. Discuss the need for antibiotics in the ED with the spine
surgeon before giving them in suspected cases of
vertebral osteomyelitis.
6. Remember to obtain blood cultures and a urine culture

Emergency Medicine Practice

16

February 2000

neoplasms, epidural infections, and herniated disks.47,49


For this reason, CT myelography is recommended in
the patient who is either unable to tolerate or has a
contraindication to MRI. CT is more available than
MRI in most hospitals, less expensive, and takes less
time. The disadvantage of CT compared to MRI
includes the fact that myelography is an invasive
procedure with inherent risks.

sure. In addition, they have the potential to delay


definitive neuroimaging. This approach, however, has
not been formally studied.

Spinal Infection
Attempt to identify the causative organism in patients
with red flags for infection. Two sets of blood cultures
as well as a urine culture should be collected before
starting antibiotics. 12,16,17,34 It is appropriate to discuss
the timing of antibiotics with the consultant. Some
consultants prefer emergent or urgent surgical investigation before antibiotics. Some patients benefit from
biopsy and culture of the suspected site of infection to
determine the responsible organism. Initiation of
antibiotics before biopsy may yield a false-negative
culture and force prolonged empiric treatment.
All patients with suspected spinal infection require
hospital admission for intravenous antibiotics. When
empiric therapy is chosen, direct it toward the most
common organism, S. aureus. 12,15,17,22,33 In patients with
suspected spinal infection, obtain an MRI within 24
hours to confirm the clinical suspicion.

Treatment
The treatment of low back pain obviously depends on
the cause. Pain management is appropriate for nearly
every patient, with the possible exception of the
hypotensive victim of a ruptured AAA.

Epidural Compression Syndromes


The patient with suspected epidural compression
requires emergent treatment and consultation. Administer high-dose dexamethasone before imaging studies.
The exact dosing is controversial; suggested treatments
range from 10-100 mg of intravenous dexamethasone. 30,46 We suggest Byrnes approach of 10 mg for the
patient with equivocal signs of compression and 100
mg for the patient with significant neurologic deficits.46
After treatment with dexamethasone, the patient
requires an emergent MRI or CT myelogram. One
question regards the need to obtain plain radiographs
before a more advanced imaging study. We recommend
against plain films, as they do not provide additional
information yet increase the cost and radiation expo-

Oh, my aching sasparilliac.Q.D. McGraw

Treatment Of Musculoskeletal Pain


Lumbosacral Strain
The best treatment approach for musculoskeletal back
pain is adequate analgesia, anti-inflammatory medication, and activity modification. Medications tradition-

Cost-Effective Strategies In Patients With Low Back Pain

IV drug users and tuberculosis patients


Unexplained weight loss or fever
Possible ankylosing spondylosis
Chronic steroid use
Symptoms that persist despite more than four weeks
of therapy
HIV

1. Limit any diagnostic workup in patients with no


red flags.
Ninety percent of patients with acute lumbosacral strain
improve with conservative therapy in 4-6 weeks. In such
patients, theres no need for x-rays or blood tests.
2. Limit MRIs.
The only time the emergency physician should order an
emergent spinal MRI is in the evaluation of a suspected
epidural compression syndrome or spinal infection. If the
patient has signs or symptoms of a herniated disc, the
patients primary care physician can order the MRI on a
routine basis.

The use of guidelines for ordering lumbar films can


decrease use by more than 20%.61
4. Limit CBCs, UAs, and ESRs.
Limit these studies to patients suspected of having
infection, tumor, or who are less than 18 years old. The
laboratory cost for a CBC, ESR, and UA are approximately
$22, $19, and $16, respectively.

3. Limit plain radiography.


Obtain only the two-view series. The five-view series is
indicated only when the patient is younger than 18 years
old and the initial two-view series appears normal.
Indications for plain films include:
Significant trauma
Age greater than 50
Minor trauma in elderly or steroid-using patients
History of malignancy
Possible motor deficit

February 2000

5. Limit specialty referral.


Unless the patient has an emergent syndrome that
requires hospital admission, such as an epidural
compression syndrome or infection, the primary care
physician can handle the outpatient evaluation. Most
patients with back pain syndromes will resolve on their
own, and very few require operative or advanced
procedures for their symptoms.

17

Emergency Medicine Practice

ally used to treat low back pain include acetaminophen, non-steroidal anti-inflammatory agents
(NSAIDs), muscle relaxants, and opioid analgesics.

manipulation. The Agency for Health Care Policy and


Research (AHCPR) states that manipulation is safe
and effective for patients in the first month of symptoms [for lumbosacral sprain], but [has] unproven
efficacy after the first month.9 However, recent
research demonstrates that manipulation was no better
than physical therapy. In terms of patient satisfaction
at one and four weeks, manipulation proved only
slightly better than a one-dollar educational booklet
given at discharge.54 A third study showed that
manipulation was no better than standard medical
therapy in terms of clinical outcome. 55

NSAIDs
NSAIDs have long been the mainstay of pharmacotherapy. Although randomized, placebo-controlled
studies of back pain are few, it is likely that most drugs
of this class are equally effective.50 The most common
side effects include gastrointestinal irritation and
deterioration of renal function. Because of these side
effects, one may consider a trial of acetaminophen
alone or in combination with an opioid or muscle
relaxant in those at risk for NSAID complications.
This at-risk population includes the elderly, those
with prior GI bleeds, and patients with impaired
renal function.

Other Modalities
Numerous modalities, including spinal traction,
massage, diathermy, ultrasound, biofeedback, transcutaneous electrical nerve stimulation (TENS), acupuncture, and trigger point injections have been used to
treat acute low back symptoms. These therapies have
no proven benefit in alleviating pain.9 One may
educate the patient on the use of heat or cold for
temporary symptom relief,9 but there are no good trials
to promote one modality over another.

Acetaminophen
Not only does acetaminophen have fewer side effects
than the NSAIDs, but it is less expensive. Acetaminophen has similar therapeutic effects as compared to
NSAIDs for other musculoskeletal conditions, such as
osteoarthritis.51 If one suggests acetaminophen alone,
consider a back-up regimen in case the acetaminophen
is insufficient. The back-up prescription could
prevent a repeat visit to the ED or the primary
physicians office.

Treatment Of Sciatica
The treatment of sciatica is similar to that of acute
lumbosacral strain, but there are some exceptions.
About 80% of patients with a herniated disc improve
with nonsurgical therapy, with only 5-10% ultimately
requiring surgery.2,24,35 Conservative management
with acetaminophen, NSAIDs, opioids, and/or
muscle relaxants is the best ED approach. As with
lumbosacral strain, the patient with sciatica should
resume routine activity as tolerated by pain. Recent
studies show that early mobilization is more effective
than bedrest. 56 Although proponents of manipulative
therapy do not consider sciatica as a contraindication
to manipulation, manipulation may cause or worsen
neurological deficits.2
While systemic corticosteroid therapy has no
proven value for either sciatica or LSS,50 epidural
steroid injections may be indicated in some patients
with sciatica. While studies give conflicting
results, 12,57-59 one meta-analysis demonstrated a marginal (10-15%) reduction in pain following epidural
steroid injection vs. placebo in patients with sciatica.50

Opioids
If the pain is more severe, give narcotic analgesics in
the ED and prescribe them for home use. The duration
is best limited to 1-2 weeks due to the risk of sedation
and constipation. Caution the patient not to combine
acetaminophen with any acetaminophen-narcotic
combination medications.
Muscle relaxants such as diazepam, carisoprodol,
and methocarbamol are also effective in treating acute
low back pain. Several studies have shown them to be
better than placebo in the treatment of low back pain. 50
However, they are no more effective than NSAIDs in
low back pain, and they have no synergistic effects
when used in combination with NSAIDs.50 They are an
alternative therapy, especially in the patient at high
risk of side effects from NSAIDs.

Bed Rest
Until the mid-1980s, patients with acute lumbosacral
strain were placed on seven days of strict bed rest.
Subsequent research demonstrated that two days of bed
rest were as effective as seven days.52 Even more recent
data indicates that even two days of bed rest may be
excessive. Studies indicate that patients who resume
normal activities as tolerated by pain recover more
rapidly than those placed at bed rest.53 Back mobilizing
exercises do not appear valuable in the acute setting.

Special Circumstances
Children and patients with a history of cancer are
the primary subsets of patients in whom serious
etiologies for back pain are most likely. The emergency
physician should use extreme caution when evaluating
these patients.

Back Pain In Children


Try to think of the last time that you evaluated a child
who suffered from atraumatic back pain. It may be

Spinal Manipulation
One especially controversial treatment option is

Emergency Medicine Practice

18

February 2000

spinal infections. Ask whether there been a change in


the childs gait, or any voluntary limitation of their
activity because of the pain. Suspect serious pathology
when children limit their activity because of the pain.
Finally, nocturnal pain raises concern for either tumor
or infection.
The physical examination is similar to that of the
adult patient, with emphasis on several areas. Specifically, examine the skin looking for birthmarks such
as caf au lait spots, which may indicate neurofibromatosis. Also, be alert for midline skin abnormalities on
the back, such as a hairy nevus, hemangioma, lipoma,
or dermoid sinus. These midline lesions can signal an

difficult to recall the casenot because you have a


weak mind, but because children rarely present to the
ED with this complaint. However, when it occurs,
back pain in children is more likely to result from a
serious etiology.7,60
When taking the history, consider several factors.
Has there been any change or increase in the patients
activity level? Specifically, has the patient started a
new exercise program, or is he or she participating in
gymnastics, football, or dance? These activities raise
concern for spondylolysis and spondylolisthesis. 60
Have there been any preceding bacterial or febrile
illnesses? Bacteremia may predispose the patient to

Ten Excuses That Dont Work In Court


serious disease. A return visit may be a red flag for
progressive or missed pathology. As many as 20% of
patients who return to the ED in 24 hours may require
emergency hospitalization.62

1. Mr. Ancien had flank pain and microscopic hematuria.


That meant a kidney stone to me.
Mr. Ancien arrested in the IVP suite. Patients with rupturing
AAAs commonly present with back pain; many have
microscopic hematuria. Not surprisingly, renal colic is the
most frequent incorrect diagnosis. Always consider AAA
early in patients who are over age 55 and complain of back
pain. Helical CT (or in the hypotensive patient, a bedside
ultrasound) are helpful if you suspect an abdominal
aneurysm.

7. He said he had the flu and complained of fever and


back pain. I was going to give him IV fluids but he had
only tracks for veins. I did give him a shot of Toradol
before discharge.
The plaintiffs attorney pointed out that ketorolac is a poor
choice for staphylococcal endocarditis. Fever is an ominous
complaint in an IV drug user.63 Fever and back pain suggest
endocarditis in this group. In one large study, 7% of all
patients with endocarditis (whether IV drug users or not)
had a chief complaint of severe back pain.64

2. He was just a kid; children never have anything seriously


wrong with their backs.
This is almost true. Actually, children rarely complain of
back pain, but when they do, it may be something serious,
or at least diagnosable. In this case, it was cancer.

8. Her radiographs were normal, so I figured she could not


have mets to her spine.
Beware the patient with a previous history of cancer and
back pain. One-quarter of patients with neurologic
complaints will have epidural metastases despite normal
radiographs. Plain radiographs will miss early tumors or
tumors within the spinal canal. If a patient with a history of
cancer has neurological findings referable to the cord, they
need an emergent MRI.

3. She only fell out of a chair. I dont x-ray every little old
lady who hurts herself when she falls.
This case was eventually dropped, since one of the
plaintiffs experts admitted that the film would not have led
to a major change in management. However, the
compression fracture caused her months of pain. In
addition, she was angry about the little old lady wisecrack.
4. I thought he was drug-seeking. It was his third visit to
the ED in less than a week complaining of pain.
People with serious disease have serious pain. Unremitting
pain despite standard management is worrisome for
tumor or infection. Look for other red flags in the history
and physical.

9. I am a careful doctorI waited for the results of the MRI


before initiating steroid therapy.
Thats not careful, thats imprudent. Do not wait for the
results of the diagnostic tests in patients with suspected
epidural compression. The tests may not be completed for
several hours, during which time symptoms may worsen. If
the patient ends up not having a compressive lesion, a
single dose of dexamethasone should not cause any
significant problems.

5. I wasnt sure if she had normal rectal tone, but she


urinated 200 cc in the ED when asked.
This patient complained of back pain and trouble urinating,
yet a post-void residual was never obtained. Urinary
retention is a red flag for cauda equina or conus
medullaris syndrome.

10. But her cancer was diagnosed over 10 years ago.


All patients with back pain and a history of cancer should
have plain radiographs of their back (unless theyre
terminally ill and require only comfort-care measures). Such
patients have an increased risk of metastases. If their
complaints are compatible with an epidural compression
syndrome, see excuses 8 and 9.

6. She had been seen by several other physicians over the


past few weeks for similar symptoms, so there could not
have been anything serious.
Beware of the patient who is seen several times in a short
period for back symptoms. There is a higher likelihood of

February 2000

19

Emergency Medicine Practice

underlying spina bifida or other spinal abnormalities.


When examining the spine, note the amount of
thoracic kyphosis and lumbar lordosis, and test for
scoliosis. Remember, however, that scoliosis alone
rarely causes pain. Finally, observe the patients gait
for any abnormalities.
The initial diagnostic evaluation of the child with
back pain should be more comprehensive than that of
the adult patient. Almost every child who presents
with back pain should have anteroposterior and lateral
radiographs of the involved spine. Oblique views may
be included if the anteroposterior and lateral films
suggest pathology. In addition to the radiographs,
consider obtaining an ESR, UA (and possibly the
unreliable CBC) depending upon a worrisome complaint, such as night pain, fever, or limitations of
activity secondary to pain. If there is suspicion for
infection, tumor, or bony abnormalities, MRI or CT
scan may be indicated.
The differential diagnosis of pediatric back pain
can be classified according to age. (See Table 5.) At age
10, problems of early childhood subside, and the new
problems of adolescence emerge. Adolescent pathologies continue until the age of 18, after which adult
etiologies predominate.

within 24 hours, if not emergently. The MRI can be


targeted to the area of radiographic disease demonstrated by plain films. If the MRI demonstrates metastases, then the study should be expanded to include
the entire spine.
In those with normal radiographs, epidural metastases are still present in up to 25%. 46 In these patients,
one may withhold dexamethasone therapy and arrange
urgent follow-up. MRI may be deferred for 3-5 days, as
long as the patients symptoms remain stable.

Group III: Patients With No Neurological


Signs Or Symptoms
Group III includes those patients with back pain
but no neurological complaints or abnormal
neurological findings. The emergency physician
should evaluate these patients with plain spinal
radiography. If normal, treat these patients conservatively with appropriate precautions and primary care
follow-up within 3-7 days. If abnormal, these patients
necessitate consultation, as they will require a localized spinal MRI. However, the MRI does not need
to be obtained on an emergent basis, nor do these
patients require dexamethasone.

Summary
Back Pain In The Patient With A History Of Cancer

No need to put the chart back in the rack! The emergency physician should view back pain as an important and manageable condition. The emergency
physician may provide a rapid yet thorough evaluation
by focusing on the red flags of the history and physical
exam. These red flags will drive further diagnostic
testing and eliminate immediate threats to life and to
the cord. Conservative treatment is the best approach
to treating back pain, as symptoms resolve within 4-6
weeks in the majority of patients. Be cautious in highrisk patients, such as the elderly, children, the
immunocompromised, and those with a history of
cancer. Adherence to these principles (and a copy of

Patients who have back pain and a history of cancer


represent a unique group. They are at risk of spinal
metastases that can produce disastrous neurological
deterioration. These patients are best categorized into
three groups based on symptoms. 30

Group I: Patients With New Or Progressive Signs


Of Neurological Compromise
Group I consists of patients with new or progressive
evidence of epidural compression. Signs and symptoms include new urinary urgency or incontinence,
weakness, numbness, paresthesias, gait disturbances,
absent reflexes, or the involvement of multiple or
bilateral spinal levels. This group is at the highest risk
of developing a complete epidural compression
syndrome over hours to days and requires emergent
intervention. (See related text.)

Table 5. Differential Diagnosis Of Back Pain In


Children By Age.
Age less than 10
diskitis
tumor
tuberculous osteomyelitis
bacterial osteomyelitis
congenital disorders

Group II: Patients With Stable Neurological Symptoms


Group II includes those patients with back pain and
neurological symptoms present for several days to
weeks. Findings are limited and may include an
isolated Babinskis sign, or radicular pain, weakness,
sensory or reflex changes in the distribution of a single
nerve root. The involvement of multiple nerve roots,
multiple spinal levels, or bilateral symptoms places
patients into Group I.
Group II patients require plain spinal radiography
of the involved spine. If radiographs are consistent
with metastatic disease, epidural extension is present
in up to 88%. 46 These patients require 10 mg of intravenous dexamethasone and should undergo a spinal MRI

Emergency Medicine Practice

Age 10 and older


spondylolysis
spondylolisthesis
Scheuermanns disease
overuse syndrome
tumor
herniated disc
vertebral osteomyelitis
ankylosing spondylitis

20

February 2000

informative references cited in the paper, as determined by the authors, will be noted by an asterisk (*)
next to the number of the reference.

the December 1999 issue of Emergency Medicine Practice,


Pain Management In The ED: Prompt, Cost-Effective,
State-of- the-Art Strategies) will make back complaints a little less painful.

1.

References
*2.

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, such
as the type of study and the number of patients in the
study, will be included in bold type following the
reference, where available. In addition, the most

3.

4.

5.

Elam KC, et al. How emergency physicians approach low


back pain: Choosing costly options. J Emerg Med
1995;13(2):143. (Physician survey; 283 questionnaires)
Frymoyer J. Back pain and sciatica. N Engl J Med 1988;318:291300. (Review)
Cypress BK. Characteristics of physician visits for back
symptoms: A national perspective. Am J Public Health
1983;73:389-395. (Retrospective; 32 million visits for
back pain)
Frymoyer J. An international challenge to the diagnosis and
treatment of disorders of the lumbar spine. Spine 1993;18:21472152. (Review)
van den Hoogen HM, Koes BW, van Eijk JT, et al. On the
accuracy of history, physical examination, and erythrocyte

Tool 1. Sample Discharge Instructions For Patients With Low Back Pain.
Copyright 2000 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants permission to reproduce this
Emergency Medicine Practice tool for institutional use.

Activity:
_____ Activity as tolerated (stop doing something if it hurts)
_____ No lifting more than ______ lbs.
_____ Other: _________________________________________________________________________________
Sleeping:
Rest on a firm mattress. If you get pain down your legs, sleeping on your side with your legs bent at the hips and
knees will help.
If you sleep on your back, putting a fat pillow under your knees may help.
Come back to the Emergency Department immediately if you develop any of the following:
Leaking urine or unable to urinate
New numbness or weakness in your legs
Inability to walk
Inibility to control your bowels
High fever
Medication:
_____ You have been given a medication that may make you sleepy or drowsy.
Do not drive yourself home from the Emergency Department
Do not drive a car or operate machinery within 12 hours of taking this medicine
Do not drink alcohol while taking this medicine
Other Medicine:
_____ Take over-the-counter ibuprofen:
_____tabs every ______ hours for _______days
_____ Other: _________________________________________________________________________________
Follow-Up:
_____ See your doctor in ____ days
_____ Call ___________ for an appointment within ________days
Other Instructions:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Remember that the emergency department is open 24 hours a day, every day, and we are always glad to
see you.

February 2000

21

Emergency Medicine Practice

sedimentation rate in diagnosing low back pain in general


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*12. Carragee EJ. Pyogenic vertebral osteomyelitis. J Bone Joint Surg
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16. Sapico FL, Montgomerie JZ. Pyogenic vertebral osteomyelitis:
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17. Ross PM, Fleming JL. Vertebral body osteomyelitis.
Clin Orthop Res 1976;118:180-190. (Retrospective study;
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18. Kiev J, Eckhardt A, Kerstein MD. Reliability and accuracy of
physical examination in detection of abdominal aortic
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19. Marston WA, Ahlquist R, Johnson G Jr, et al. Misdiagnosis of
ruptured abdominal aortic aneurysms. J Vasc Surg
1992;16(1):17-22.
20. Lederle FA, Walker JM, Reinke DB. Selective screening for
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ultrasound. Arch Intern Med 1988;148:1753-1756.
*21. Deyo R, Rainville J, Kent D. What can the history and physical
examination tell us about low back pain? JAMA 1992;286:760765. (Review)
22. Bonfiglio M, Lange TA, Kim YM. Pyogenic vertebral
osteomyelitis. Clin Orthop Rel Res 1973;96:234-247. (Case
series; 53 patients)
23. Basmajian JV, Burke MD, Burnett GW, et al. Stedmans Medical
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(Medical dictionary)
24. Deyo RA, Loeser JD, Bigos SJ. Herniated intervertebral disk.
Ann Intern Med 1990;112:598-603. (Review)
25. Deol GS, Van Der Bauwhede J, Sherry E. Wheeless Textbook of
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26. Herr CH, Williams JC. Supralevator anorectal abscess
presenting as acute low back pain and sciatica. Ann Emerg
Med 1994;23:132-135. (Case report)
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physical signs in low back pain. Spine 1980;5:117-125. (Clinical

Emergency Medicine Practice

28.

29.
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*31.

32.

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22

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Main CJ, Waddell G. Behavioral responses to examination: A
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Mazanec DJ. Evaluating back pain in older patients. Cleveland
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Portenoy R, Lipton R, Foley K. Back pain in the cancer patient:
An algorithm for evaluation and management. Neurology
1987;37:134-138. (Review)
Helweg-Larsen S. Clinical outcome in metastatic spinal cord
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Rothman S. The diagnosis of infections of the spine by
modern imaging techniques. Ortho Clin North Am 1996;27:1531. (Review)
Wheeler D, Keiser P, Rigamonti D, et al. Medical management
of spinal epidural abscesses: Case report and review. Clin
Infect Dis 1992;15:22-27. (Case report and review of 37 cases)
Wisneski R. Infectious disease of the spine: Diagnostic and
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Scavone JG, Latshaw RF, Rohrer GV. Use of lumbar spine
films. JAMA 1981;246:1105-1108. (Retrospective; 871 patients)
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JAMA 1997;277:1782-1786. (Retrospective; 963 patients)
Martin R, Yuan H. Neurosurgical care of spinal epidural,
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Borenstein DG. A clinicians approach to acute low back pain.
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Bove P, Kaplan D, Dalrymple N, et al. Reexamining the value
of hematuria testing in patients with acute flank pain. J Urol
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Pomper SR, Fiorillo MA, Anderson CW, et al. Hematuria
associated with ruptured abdominal aortic aneurysms.
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factors delaying surgery in ruptured abdominal aortic
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(Prospective; 30 patients)
Pinson AG, Philbrick JT, Lindbeck GH, et al. Fever in the
clinical diagnosis of acute pyelonephritis. Am J Emerg Med
1997;15(2):148-151. (Retrospective; 304 patients)
Adams KK, Jackson CE, Rauch RA, et al. Cervical myelopathy
with false localizing sensory levels. Arch Neurol 1996;53:11551158. (Case series; 4 patients)
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A prospective investigation. J Bone Joint Surg Am 1990;72:403408. (Prospective; 67 patients)
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Deyo R. Drug therapy for back pain: Which drugs help which
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52.

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63.

64.

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13. Which of the following is false regarding


herniated disc?
a. The prognosis is good, in that ultimately only
5-10% of all patients require surgery.
b. MRI should be ordered from the ED so that it
will occur within 24 hours of ED discharge.
c. The emergency physician may consider obtaining plain spinal radiographs to rule out other
bony diseases that may mimic herniated disc.
d. The crossed straight leg raise test is highly
specific but insensitive for herniated disc.
14. Which of the following is false regarding the
treatment of lumbosacral strain?
a. Bedrest for three days is more beneficial than
continuing routine activity.
b. NSAIDs are useful therapy and should be
prescribed in most cases.
c. Opioid analgesics should be prescribed for the
more severe episodes, but only for a short time.
d. Muscle relaxants are beneficial therapy.
15. MRI is the gold standard test for all of the following problems except:
a. epidural compression syndrome.
b. herniated disc.
c. spinal infection.
d. vertebral fracture.
16. Which of the following is not indicated in the
patient with suspected spinal infection?
a. Complete blood count
b. Erythrocyte sedimentation rate
c. Plain spinal radiographs
d. Serum calcium level
e. Urinalysis
17. Which of the following is true regarding back pain
in children?
a. It is generally a benign disease similar to that in
the adult patient.
b. Most patients should have plain spinal radiographs obtained.
c. Caf-au-lait spots are commonly seen and
indicate an underlying spina bifida occulta.
d. Night pain is a common complaint in children
and is not concerning.

Physician CME Questions


11. Which of the following is not a red flag of low
back pain?
a. Age less than 18 years
b. Pain for more than two weeks
c. Pain that awakens the patient from sleep
d. Injection drug use

18. In evaluating the patient with suspected


epidural compression:
a. antibiotics should be given at the outset of the
evaluation, as the patient may be going to the
operating room.
b. CT scan without contrast is the gold
standard test.
c. dexamethasone IV should be given at the outset,
before obtaining diagnostic testing.
d. plain spinal radiography, if normal, will allow one
to delay further diagnostic testing for 24-48 hours.

12. In patients with suspected spinal infection:


a. the WBC count is universally elevated.
b. the ESR is frequently elevated.
c. blood cultures are a waste of money.
d. the most common organism is
Streptococcus pneumoniae.

February 2000

23

Emergency Medicine Practice

Physician CME Information

19. In patients with back pain and a history of cancer:


a. all of them should have plain spinal radiographs
obtained at the initial visit.
b. all of them require an MRI within 24 hours due
to the risk of metastases.
c. there should be no concern of spinal metastases
as long as the neurological exam is normal.
d. all of them should be started on dexamethasone
orally, even if the ED evaluation is negative.

This CME enduring material is sponsored by Carolinas HealthCare System


and has been planned and implemented in accordance with the Essentials
and Standards of the Accreditation Council for Continuing Medical
Education. Credit may be obtained by reading each issue and completing
the post-tests administered in December and June.
Target A udienc e: This enduring material is designed for emergency
medicine physicians.
Needs A ssessmen t: The need for this educational activity was determined
by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS,
and ACEP; and evaluation of prior activities for emergency physicians.
Date of O riginal R elease: This issue of Emergency Medicine Practice
was published February 1, 2000. This activity is eligible for CME credit
through February 1, 2001. The latest review of this material was
January 26, 2000.
Discussion of I nvestiga tional I nformation: As part of the newsletter,
faculty may be presenting investigational information about
pharmaceutical products that is outside Food and Drug Administration
approved labeling. Information presented as part of this activity is
intended solely as continuing medical education and is not intended
to promote off-label use of any pharmaceutical product. Disclosure of
Off-Label Usage: This issue of Emergency Medicine Practice discusses no offlabel use of any phamaceutical product.
Facult y Disclosur e: In compliance with all ACCME Essentials, Standards,
and Guidelines, all faculty for this CME activity were asked to complete a
full disclosure statement. The information received is as follows: Dr. DellaGiustina,Dr. Kilcline, Dr. Denny, and Dr. Jagoda report no significant
financial interest or other relationship with the manufacturer(s) of any
commercial product(s) discussed in this educational presentation.
Accreditation: Carolinas HealthCare System is accredited by the
Accreditation Council for Continuing Medical Education to sponsor
continuing medical education for physicians.
Credit D esigna tion: Carolinas HealthCare System designates this
educational activity for up to 2 hours of Category 1 credit toward the
AMA Physicians Recognition Award. Each physician should claim only
those hours of credit actually spent in the educational activity. Emergency
Medicine Practice is approved by the American College of Emergency Physicians for 24 hours of ACEP Category 1 credit (per annual subscription).
Earning C redit: Physicians with current and valid licenses in the United
States, who read all CME articles during each Emergency Medicine Practice
six-month testing period, complete the CME Evaluation Form distributed
with the December and June issues, and return it according to the
published instructions are eligible for up to 2 hours of Category 1 credit
toward the AMA Physicians Recognition Award (PRA) for each issue. You
must complete both the post-test and CME Evaluation Form to receive
credit. Results will be kept confidential. CME certificates will be mailed to
each participant scoring higher than 70% at the end of the calendar year.

20. Which of the following is not a routine


treatment measure that should be applied
for lumbosacral strain?
a. Acetaminophen
b. Activity modification to the extent tolerated
by the pain
c. Opioid analgesics
d. Systemic corticosteroids

Class Of Evidence Definitions


Each action in the clinical pathways section of Emergency
Medicine Practice receives an alpha-numerical score based on
the following definitions.
Class I
Always acceptable, safe
Definitely useful
Proven in both efficacy
and effectiveness
Must be used in the
intended manner for
proper clinical indications
Level of Evidence:
One or more large
prospective studies
are present (with
rare exceptions)
Study results consistently
positive and compelling
Class IIa
Safe, acceptable
Clinically useful
Considered treatments
of choice
Level of Evidence:
Generally higher levels
of evidence
Results are consistently
positive
Class IIb
Safe, acceptable
Clinically useful
Considered optional or
alternative treatments
Level of Evidence:
Generally lower or
intermediate levels
of evidence
Generally, but not
consistently, positive results

Emergency Medicine Practice

Class III:
Unacceptable
Not useful clinically
May be harmful
Level of Evidence:
No positive high-level data
Some studies suggest or
confirm harm
Indeterminate
Continuing area of research
No recommendations until
further research
Level of Evidence:
Evidence not available
Higher studies in progress
Results inconsistent,
contradictory
Results not compelling

Publisher : Robert Williford. Vice Presiden t/General Manager : Connie Austin.


Executiv e Editor: Heidi Frost.

Direct all editorial or subscription-related questions to Pinnacle


Publishing, Inc.: 1-800-788-1900 or 770-565-1763
Fax: 770-565-8232
Pinnacle Publishing, Inc.
P.O. Box 72255
Marietta, GA 30007-2255
E-mail: emer gmed@pinpub .com

Adapted from: The Emergency


Cardiovascular Care Committees
of the American Heart Association
and representatives from the
resuscitation councils of ILCOR:
How to Develop Evidence-Based
Guidelines for Emergency Cardiac
Care: Quality of Evidence and
Classes of Recommendations; also:
Anonymous. Guidelines for
cardiopulmonary resuscitation and
emergency cardiac care. Emergency Cardiac Care Committee and
Subcommittees, American Heart
Association. Part IX. Ensuring
effectiveness of community-wide
emergency cardiac care. JAMA
1992;268(16):2289-2295.

Pinnacle Web Site: http://www .pinpub .com


Emergency Medicine Practice (ISSN 1524-1971) is published monthly (12 times per year)
by Pinnacle Publishing, Inc., 1503 Johnson Ferry Road, Suite 100, Marietta, GA 30062.
Opinions expressed are not necessarily those of this publication. Mention of products
or services does not constitute endorsement. This publication is intended as a general
guide and is intended to supplement, rather than substitute, professional judgment. It
covers a highly technical and complex subject and should not be used for making
specific medical decisions. The materials contained herein are not intended to
establish policy, procedure, or standard of care. Emergency Medicine Practice is a
trademark of Pinnacle Publishing, Inc. Copyright 2000 Pinnacle Publishing, Inc. All
rights reserved. No part of this publication may be reproduced in any format without
written consent of Pinnacle Publishing, Inc. Subscription price: $249, U.S. funds. (Call for
international shipping prices.)

24

February 2000