The Medical Media Review

Back Pain: a “Worst First” Approach

• By Mark Yoffe MD
• 16 May, 2012
• No Comments

When it comes to back pain, think of the worst, i.e. the most dangerous ones, first. That way you won’t miss anything critical, either in real life or on the Boards.

• Cardiovascular
  • Upper back pain: consider acute coronary syndrome or thoracic aortic dissection, particularly if pain is tearing
  • Lower back pain: consider abdominal aortic aneurism or rupture (older smoker) and retroperitoneal hematoma. Look for distended abdomen, pulsatile abdominal mass or bruit, diminished femoral pulses or sudden unexplained anemia or volume loss
  • Acute hemolytic transfusion reactions
• Infectious
  • Look for toxic appearance, fever, rigors, leukocytosis, fluctuant mass, dysuria, vaginal discharge, or
  • immunocompromised states (glucocorticoid use, recent back injections or surgery, IV drug use, HIV, asplenia)
  • Herpes zoster (shingles)
• Malignant
  • personal history of cancer, or
  • unexplained fatigue, weight loss, anorexia, lymphadenopathy, nocturnal bony pain, pain not relieved with rest or immobility, night sweats
  • unexplained  hypercalcemia or microcytic anemia, and renal failure (multiple myeloma)
  • new urinary retention or incontinence, saddle anesthesia, progressive weakness
• Traumatic
  • Major trauma, or even minor trauma in a frail, osteoporotic, or glucocorticoid-using patient
  • Look for tenderness over spinous processes
• Immune-mediated
  • seronegative spondyloarthropathies (= arthritidis of the spine which are rheumatoid factor negative)
    • ankylosing spondylitis: insidious onset of morning stiffness in a younger (<40), often male patient which improves with activity and is often associated with uveitis (erythema, pain, blurry vision, photophobia, lacrimation), enthesitis, peripheral joint involvement, kyphosis, restrictive lung disease, and cardiovascular problems (get CBC, ESR and radiograph of spine)
    • reactive arthritis: younger patient with (a) asymmetric arthritis, (b) urethritis, and (c) conjunctivitis, or keratoderma blenorrhagicum in the setting of recent dysuria or diarrheal illness (as appropriate, get plain radiographs, genital swab or PCR of urine for Chlamydia and/or work up any diarrhea for infectious causes)
    • psoriatic arthritis: look for arthritis and well-circumscribed, erythematous, scaly plaques on extensor surfaces, dactylitis (sausage-shaped = defuse fusiform swelling of an entire digit), nail pitting, onycholysis, pencil-in-cup deformity (= pointed articular surfaces of proximal bone which appear as though they were tapered by  a pencil sharpener, along with saucerization of distal articular surface) on radiograph.
    • enteropathic arthritis: associated with inflammatory bowel disease or Whipple’s disease (get endoscopy, etc.)
• Lumbar spinal stenosis (lower back pain that is worse with walking on level ground or standing, and better with walking uphill or stooping over a supportive object such as a shopping cart or walker)
• Mechanical
  • The most common cause of back pain
  • Typical presentation is of sudden onset of lower back pain, associated with mechanical stress and improved with rest, in an otherwise sedentary and often overweight or obese patient
  • “Nearly all regional backache is of indeterminate causation…. Mechanical low back pain and sciatica due to disc herniation is a transient, self-limiting condition. Patients should be told this…. The reassurance you thus provide is priceless…. Three minutes
    talking with the patient can be more helpful than anything else you have to offer. NEVER mention to the patient the words ‘disc,’ ‘spasm,’ or ‘sciatica.’” A Short Orthopedics Text for Emergency Physicians  (2001) by Merrill A. Cohen MD (pp. 45 & 55).
  • Pediatric back pain should be viewed with particular suspicion for badness. (More here.) The younger the child the more likely it is that the cause is not benign.

References

• Pocket Medicine (2010) by Marc S. Sabatine MD MPH, Editor (excellent coverage of seronegative spondyloarthropathies at 8-7)
• Am Fam Physician. 2012 Feb 15;85(4):343-50. Diagnosis and treatment of acute low back pain. Casazza BA.
• The Merck Manual for Health Care Professionals: Seronegative Spondyloarthropathies.
•  A Short Orthopedics Text for Emergency Physicians by Merrill A. Cohen MD (2001)
• Minor Emergencies by Philip Buttaravoli MD (2012)

by  Mark Yoffe MD