Living in the Grey Zone: Back Pain

Thanks to all who participated and attended the Grey Zone: Acute Back Pain lecture last Tuesday.  I learned a lot, hope that you did as well.  As is often the case with grey zone lectures, we spend so much time talking with the panel that we miss some of the didactics at the end.  Here are some highlights that I wanted to be sure to cover.

99% of patients will acute back pain will get better, often without you doing much at all.  Gentle activity, NSAIDs, and time will take care of most.  If it goes on for two-week or so, add some formal PT. The activity is good, but PT will also use massage, heat, TENS and US to help get the muscles to relax.

Red flags aren’t all they are made out to be, but are definitely a clue to slow down your thinking about a patient with back pain.  You may not need to do more just because a patient has one red flag-  80% of patients will have at least one.

Yellow Lights mean “slow down and prepare to stop” according to my 5-year-old, and that is just what these should signs and symptoms should make you do.

  • Age >70
  • History of cancer, not active malignancy
  • IV drug use
  • Osteoporosis, use of steroids
  • Immunosuppression

On the other hand, the red lights should make you stop and seriously consider more imaging, consultation, or other workup. You may still be justified in delaying imaging if there are one of these present, but you need to be extra sure that it is the right thing to do.

  • Known metastatic cancer
  • Trauma
  • Recent spinal surgery
  • Bowel/Bladder incontinence
  • Fever (without another reason)
  • Weight loss (without another reason)
  • Saddle anesthesia, decreased rectal tone
  • Progressive motor or sensory loss

If you do need to do more workup, let your differential diagnosis be your guide as to what needs to happen.  Here are some suggestions:

  • Vertebral Fracture: either from osteoporosis or trauma.  Plain films are quite helpful, CT is important for traumatic fractures- will give a better idea of the extent of the fracture and the mechanism.
  • Metastatic disease: Plain films are a place to start.  MRI would be quick to follow if there are neurologic findings.  Bone scan may be useful in a high risk patient with a less clear picture.
  • Cauda Equina Syndrome: Think this if there is saddle anesthesia, bowel/bladder incontinence. MRI if you are concerned, with quick referral to NSGY.
  • Spinal Stenosis: Pseudoclaudication is the classic sx here: predictable pain with standing or walking, better with rest.  Vascular claudication gets better quickly with rest, pseudoclaudication takes 20-30 minutes or more. Plain films may show misalignment, but the MRI is going to clinch the diagnosis.
  • Epidural abcess: Unexplained fever and weight loss in a high risk patient: IV drugs, recent spinal surgery, recently septic, decubital ulcers all are all risks. MRI is the imaging test.

Here’s a great patient centered video about low back pain to bring these points home to your patients.