Back pain management

[ACal]

I'm almost 2 years out of training, still have some doubts regarding managing nontraumatic lower back pain in the ER:

Obviously in people with no red flags, treat symptomatically and discharge.

The main problem are these patient who usually have some worsening of their chronic back pain, coming in with some mild neuro complaint like one leg is starting to feel numb or a little weak, or some numbness in the groin. Assuming infectious workup is negative and they get a MRI non-con, always shows some type of degenerative disease/spinal stenosis/disc bulge/nerve root compression...etc. (Usually it's a patient who was signed out to me to follow up on the MRI since I work a lot of night shifts)
If it's an obvious compression I'll call neurosurgery. But what do you guys do with these nonspecific MRI findings and maybe some subjective leg numbness? Call neurosurgery in the middle of the night anyways and get yelled at? Try to admit for PT?

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[Pudortu]

If no true red flags or physical exam findings, I give some pain meds and discharge. Numbness doesn’t count for me unless they describe saddle anesthesia. Rarely get mri. Follow up with pcp for that. Explain how it sucks and how it’s treated with pain meds, physical therapy as an outpatient, or neurosurgery once all that fails. I discharge without any workup about 95% of my back pains.

 

[UODOCPDX]

I'm almost 2 years out of training, still have some doubts regarding managing nontraumatic lower back pain in the ER:

Obviously in people with no red flags, treat symptomatically and discharge.

The main problem are these patient who usually have some worsening of their chronic back pain, coming in with some mild neuro complaint like one leg is starting to feel numb or a little weak, or some numbness in the groin. Assuming infectious workup is negative and they get a MRI non-con, always shows some type of degenerative disease/spinal stenosis/disc bulge/nerve root compression...etc. (Usually it's a patient who was signed out to me to follow up on the MRI since I work a lot of night shifts)
If it's an obvious compression I'll call neurosurgery. But what do you guys do with these nonspecific MRI findings and maybe some subjective leg numbness? Call neurosurgery in the middle of the night anyways and get yelled at? Try to admit for PT?

If the MRI is negative for anything acute and symptoms are mild with only mild numbness and not red flags like saddle anesthesia you could try outpatient referral to PT, a short course of Prednisone and/or Gabapentin for the neuropathic pain, NSAIDs/Muscle relaxers/Opoids for pain control, and outpatient referral to PM&R (Epidural injections of steroids) and neurosurgery (outpatient surgery) as a last resort.

It certainly wouldn’t be unreasonable to consult with neurosurgeon to CYA, but if symptoms are just mild leg numbness I don’t know if you would admit for PT unless are symptoms severe and they can’t make it at home or need to rule something else?

Feel free to correct me if I am wrong.

I am sure responses will very a lot depending on resources at each hospital.

 

[Rekt]

Sounds like your partners need education on when MRIs are indicated more than anything.

 

[JacobMcCandles]

Discharge with referral to pain management or back to their PCP.

 

[Birdstrike]

If it's an obvious compression I'll call neurosurgery. But what do you guys do with these nonspecific MRI findings and maybe some subjective leg numbness? Call neurosurgery in the middle of the night anyways and get yelled at? Try to admit for PT?

20 years out of training, boarded in EM and Pain Medicine. What you describe is 90% of what I see.

Assuming we are dealing with peripheral nerves, “subjective leg numbness” in a dermatome, in the setting of a nerve root impingement, is not an indication for urgent surgical decompression. I see these all day long and don’t involve a neurosurgeon, on an urgent basis, if ever.

Many of such acute symptoms resolve over a few weeks. If not, then PT/nsaids. If still in pain, epidural steroid injections. If still in pain, then surgical consult.

These play out over weeks to months. Rarely do these immediately get surgery upon the first identification of a disc or osteophyte contacting a nerve root.

Exceptions:

-Acute, objective, motor deficit (eg, foot drop) detectable on exam

-Cauda equine syndrome

-Epidural abscess/discitis/osteomyelitis

-Epidural hematoma

-Cord compression with clinical or radiologic evidence of myelopathy.


If no red flags: Primary care > Interventional Pain > Neurosurgery or Ortho-Spine. Most never get to the surgical end of that pathway.

 

[BoardingDoc]

some mild neuro complaint like one leg is starting to feel numb or a little weak ... they get a MRI non-con

What? Why are you getting an MRI on these patients at all? If they have objective weakness on exam, that's one thing. If they have vague acute on chronic symptoms, they get symptomatic treatment, outpatient referral and a DC.

Agree with @Rekt more than anything in that it sounds like y'all are ordering WAY too many MRIs.

 

[pkwraith]

If your partners are signing out essentially outpatient mri to you, then you should order a mri with contrast and then sign it back out to them for dayshift

 

[WorkNoteEmergency]

MRI is only available at not quite even lazy banker's hours in my ED. I can't even remember the last time I ordered MRI for a back problem, or transferred someone out for one. Sensory symptoms referrable to there lumbar spine don't get too much interest from me. If a person complains of saddle anesthesia or similar, they get a rectal exam. People complain of inontinence but it's pretty easy to sort out true overflow incontinence from "I peed my pants because it hurts to get up and go to the toilet"

Remember, even though the outsiders don't want to believe this, we're looking for emergencies and non specific findings on an MRI don't constitute one, so you can have the MRI printed to a disc and give it to the patient with the phone number for the primary care doctor or a back doctor.

 

[DrDrummer]

-Cord compression with clinical or radiologic evidence of myelopathy.

I think of numbness/tingling as a potential sign of myelopathy from cord or nerve root compression. I see this frequently, often with normal reflexes, normal strength, normal gait and I usually ask people to stand on heels/toes as part of my back/neck pain exam. If they don't have abnormal findings on those tests, I generally treat conservatively and refer for follow up if no improvement.

You mentioned you don't think of numbness/tingling as a concerning red flag. Is that only when it is confined to a dermatome suggesting nerve root compression as opposed to spinal compression from stenosis or something else? How do you discriminate between these, or what clinical signs or symptoms are you looking for that would prompt you to consult a surgeon?

 

[Birdstrike]

I think of numbness/tingling as a potential sign of myelopathy from cord or nerve root compression. I see this frequently, often with normal reflexes, normal strength, normal gait and I usually ask people to stand on heels/toes as part of my back/neck pain exam. If they don't have abnormal findings on those tests, I generally treat conservatively and refer for follow up if no improvement.

You are correct. Checking for imbalance is important since often myelopathy from cord compression affects the dorsal columns (proprioception).

You mentioned you don't think of numbness/tingling as a concerning red flag. Is that only when it is confined to a dermatome suggesting nerve root compression as opposed to spinal compression from stenosis or something else?

I didn't say numbness/tingling couldn't be a red flag. I prefaced that with the assumption the numbness was "peripheral," and in a
"dermatome." So, yes, if someone says there tingling sensation is only in two fingers, that's much more likely to be a nerve root sense it's dermatomal and unilateral. If it's a whole arm, bilateral, or an arm or a leg, then you have to wonder what's being affected that can cover that much territory? I disc compressing a single nerve roots shouldn't do that. That's more likely to be CNS, including the cord.

Also, severe pain with the sensory symptoms, is actually a little bit reassuring, if you think about it. CNS compression by itself, doesn't cause pain. Unfortunately, in the chronic form, people can have bad enough pathology from multiple bulging discs encroaching on the central canal (cord, myelopathy) and one or more nerve roots, and you can have mixed overlapping symptoms. But generally, compressed brain or cord, are insensate.

In general, unilateral symptoms, localized to one dermatome, with pain out of proportion to sensory and motor findings, leans heavily in the direction of being a nerve root problem.

Painless or bilateral motor or sensory symptoms, particularly out of proportion to pain, leans heavily towards a something central (usually cord if bilateral, could also be brain, if unilateral). Also, imbalance is a very specific sign, since a single nerve root compression can't truly cause imbalance. They may have a weak extremity or have an affected gait due to pain, but when asked to close their eyes and stand still, they shouldn't fall over (Romberg).

Also, keep in mind "Low back pain" is very unlikely to affect the spinal cord, unless it's at L1/2. The cord ends at L1 or L2 at the lowest. And if it does affect the cord here, you're going to have only leg and bowel/bladder symptoms.

All bets are off, if you have fever, cancer, trauma, IV drug use or recent spine manipulation (surgery, needle).

 

[GoBeers]

please dont discharge with opioids. What's the end game with opioids if it's likely a chronic problem that may or may not have simply just been "aggravated."?

once these patients get a taste of opioids (which of course will help short term), then that's all they'll know to ask for to their pcp or pain clinic. of course we know that majority of time, chronic opioids aren't indicated or have poor long term outcomes, especially for mechanical pain. it simply makes the PCP or the pain doctor the bad guy when we decline to provide opioids

 

[Birdstrike]

please dont discharge with opioids.

Thank you. As a Pain Physician, it drives me nuts when someone comes and is already on opiates. 99 out of a 100 times, if they're not yet on opiates, I can get they're pain under adequate control without it. It might take some injections, anti-inflammatories, non-benzo muscle relaxers, PT or a non-opiate adjuvant (gabapentinoid, cymbalta, or other).

 

[TeddyBoomBoom]

I have *no* problem waking up nsg or calling in an MRI tech if I think I have to, but unless I think there is an acute surgical emergency, then I’m not doing any of those things and I’m likely dc-ing this person home with nsg follow up.

I MRI back pain probably twice/yr, and probably wake up nsg for back pain roughly the same.

If I document a reassuring H&P and get a normal-enough CT read by Rads, that’s good enough for me.
🤷‍♀️

Edit: also much what Birdtrike just said

 

[Mount Asclepius]

I have *no* problem waking up nsg or calling in an MRI tech if I think I have to, but unless I think there is an acute surgical emergency, then I’m not doing any of those things and I’m likely dc-ing this person home with nsg follow up.

I MRI back pain probably twice/yr, and probably wake up nsg for back pain roughly the same.

If I document a reassuring H&P and get a normal-enough CT read by Rads, that’s good enough for me.
🤷‍♀️

Edit: also much what Birdtrike just said

You are CT’ing back pain? What’s a normal enough CT? This sounds about as odd as ordering a bunch of non-emergent MRIs for back pain in the ED.

 

[RustedFox]

You are CT’ing back pain? What’s a normal enough CT? This sounds about as odd as ordering a bunch of non-emergent MRIs for back pain in the ED.

I'll do this sometimes; but it's a far more high-yield study in my patient population. READ: The Ancients.

 

[ACal]

20 years out of training, boarded in EM and Pain Medicine. What you describe is 90% of what I see.

Assuming we are dealing with peripheral nerves, “subjective leg numbness” in a dermatome, in the setting of a nerve root impingement, is not an indication for urgent surgical decompression. I see these all day long and don’t involve a neurosurgeon, on an urgent basis, if ever.

Many of such acute symptoms resolve over a few weeks. If not, then PT/nsaids. If still in pain, epidural steroid injections. If still in pain, then surgical consult.

These play out over weeks to months. Rarely do these immediately get surgery upon the first identification of a disc or osteophyte contacting a nerve root.

Exceptions:

-Acute, objective, motor deficit (eg, foot drop) detectable on exam

-Cauda equine syndrome

-Epidural abscess/discitis/osteomyelitis

-Epidural hematoma

-Cord compression with clinical or radiologic evidence of myelopathy.

Thank you for your input!

I might be wrong but isn't a foot drop usually from peripheral nerve issue like peroneal nerve compression?
Also for people found to have severe stenosis or significant disc bulging and compression of the nerve root leading to objective leg weakness, does that warrant a NS consult?

 

[Birdstrike]

Thank you for your input!

I might be wrong but isn't a foot drop usually from peripheral nerve issue like peroneal nerve compression?

It definitely can come from either common (or deep) peroneal nerve compression. But I'm not sure what the text books would say is most common overall. In my practice, I see it more often from chronic nerve root compression in the spine, usually L5 (or L4), because I get sent a lot of back pain patients. I have a few patients with it, from MS and Charcot-Marie-Tooth. If I have someone with a foot drop from a peroneal nerve problem, that's harder for me to treat with a needle. I'm usually throwing that in neuro's lap, for an EMG. But if peripheral, I doubt neurosurg would do anything with that. I suppose it depends what has injured the nerve.

If a foot drop from an L5 compressed by a disc, however, neurosurgery loves to operate on those.

Also for people found to have severe stenosis or significant disc bulging and compression of the nerve root leading to objective leg weakness, does that warrant a NS consult?

As far as "stenosis," it depends on which type. Stenosis could refer to central canal stenosis (with or without neurogenic claudication), foramina stenosis (with or without nerve root involvement) or lateral recess (which is in the lateral canal, but not quite in the foramen) stenosis, which can also affect nerve roots.

It's not wrong to send these patients to neurosurgery. It's not uncommon for them to have a motor deficit if the problem is severe and progressive. But it doesn't mean neurosurgery is going to operate on all, or even most of them.

A lot of times neurosurgeons kick these patients over to me, saying, "Try injections before you consider surgery." That's mainly because success rates for these problems, in the lumbar spine particularly, aren't as good as you'd think. Also, many of these patients are poor surgical candidates, or have other confounding pain generators that the surgeons can't fix (facet joint pain, SI joint pain, discogenic pain, psychogenic pain, muscular pain etc) by decompressing whatever nerves are compressed.

Most nerve root compression are not surgical ermegencies. However, a foot drop can screw up your gait for life, if it's allowed to linger and become permanent. Similarly, caudal equina compression, which is essentially a nerve root compression of sacral nerves, can cause enough permanent bladder dysfunction that someone might have to self-cath for life, if it is allowed to become chronic. So, yes, neurosurgery consult. sooner rather than later, on these.

Similarly, severe lumbar central canal stenosis with enough nerve compression to cause neurogenic claudication, needs to see a neurosurgeon at some point. But many of these patients are elderly, poor surgical candidates and often want to try to avoid surgery, as do the surgeons. Sometimes the surgeons also kick these back to me to try injections, when really the only thing that's going to help is decompressing the nerves. But on a 90 year old, with co-morbidities, that doesn't want surgery and has a surgeon who doesn't want to operate, sometimes you're stuck spinning your wheels.

 

[Birdstrike]

Honestly, though, I think you guys generally do a great job of ruling out emergent causes of back pain. Don't worry about getting too deep in the weeds regarding the minutia.

As long as you keep ruling out AAAs, acute epidural abscesses/osteomyelitis/discitis, epidural hematoma, peyelonephritis, PE, thoracic aortic dissection, unstable fracture with cord injury, posterior wall MI/ischemia, acute-tumor cord compression, and caudal equina syndrome, most of the other stuff can wait.

 

[skougess]

Honestly, though, I think you guys generally do a great job of ruling out emergent causes of back pain. Don't worry about getting too deep in the weeds regarding the minutia.

As long as you keep ruling out AAAs, acute epidural abscesses/osteomyelitis/discitis, epidural hematoma, peyelonephritis, PE, thoracic aortic dissection, unstable fracture with cord injury, posterior wall MI/ischemia, acute-tumor cord compression, and caudal equina syndrome, most of the other stuff can wait.

Thank you for saying this. What ever happened to “is this musculoskeletal? Then are you able to control your bladder and can you stand? Then gtfo please.”

 

[Birdstrike]

Thank you for saying this. What ever happened to “is this musculoskeletal? Then are you able to control your bladder and can you stand? Then gtfo please.”

A big part of what makes a great ER doc is being able to cut through the crap and boil a situation down to its essentials, which you’ve rightly done.

 

[thegenius]

I'm almost 2 years out of training, still have some doubts regarding managing nontraumatic lower back pain in the ER:

Obviously in people with no red flags, treat symptomatically and discharge.

The main problem are these patient who usually have some worsening of their chronic back pain, coming in with some mild neuro complaint like one leg is starting to feel numb or a little weak, or some numbness in the groin. Assuming infectious workup is negative and they get a MRI non-con, always shows some type of degenerative disease/spinal stenosis/disc bulge/nerve root compression...etc. (Usually it's a patient who was signed out to me to follow up on the MRI since I work a lot of night shifts)
If it's an obvious compression I'll call neurosurgery. But what do you guys do with these nonspecific MRI findings and maybe some subjective leg numbness? Call neurosurgery in the middle of the night anyways and get yelled at? Try to admit for PT?

I try very hard to send these patients home without imaging. If I'm forced to follow-up on an MRI, I'll try to discharge them anyway. I try very hard not to call NSG in the middle of the night. For what reason? Problem is hospitalists don't want to take the patient because the consult wasn't called, and they are *uss**s for not wanting to call NSG. It's a real shame

 

[thegenius]

Tintinalli's is very clear that if you have classic sciatica with neuro symptoms and without red flags (trauma, fever, cancer, etc) to not do an MRI in the ER. It's even written in BOLD.

 

[thegenius]

As long as you keep ruling out AAAs, acute epidural abscesses/osteomyelitis/discitis, epidural hematoma, peyelonephritis, PE, thoracic aortic dissection, unstable fracture with cord injury, posterior wall MI/ischemia, acute-tumor cord compression, and caudal equina syndrome, most of the other stuff can wait.

Many of those require an MRI!

 

[medninja]

I really hate this chief complaint and MRI exclusively for red flags, at least for lumbar pain pts. That said, these patents become Kasparovs of annoying and I find my self in check occasionally, even involuntarily mated more than I like to recall. I’ve had an MRI show “severe” stenosis and I’ve called NSG only to hear spinal stenosis hurts, they’ll need an intervention only if their wallet hypertrophies, and in the meantime they can abuse me for relief. I’ve even successfully admitted a pt with saddle anesthesia and severe, central compression with cord signal, but ultimately NSG obs’d the pt before discharging the next day with outpt follow up.

I appreciate the pearls outlined above, but is there a definitive way to definitively rule out cauda equina in the setting of severe stenosis without relying on subjective reporting from pts? Was the NSG’s exam just so much better that their worries were relieved? I find half of these patients ostensibly can’t ambulate, making Romberg testing impossible, but also don’t have any bounce backs leading to admission from those I have wheeled out.

Does the rouse fail under constant scrutiny, or do they just feel better?

Moreover, what are absolute red flags for cervical central impingement beyond pain and total bilateral arm numbness/weakness where there’s already cord pathologies that prompt imaging?

I’ve also read systematic steroids are worthless for this (just like acute spinal trauma) but see medrol dose packs prescribed like skittles. NSG prescribes them. Am I also supposed to start ramping pts up on gabapentin?

I think I’d be much more empathetic with the 99%+ pts that I discharge if I had the education to not worry about the tiny few that put me through so much work, seemingly unnecessarily.

 

[skougess]

I appreciate the pearls outlined above, but is there a definitive way to definitively rule out cauda equina in the setting of severe stenosis without relying on subjective reporting from pts? Was the NSG’s exam just so much better that their worries were relieved? I find half of these patients ostensibly can’t ambulate, making Romberg testing impossible, but also don’t have any bounce backs leading to admission from those I have wheeled out.

I try my best to turn the subjective into the objective. 99% of these patients were witnessed standing/walking by nursing when they arrived, despite the show they put on for you in the exam room. Boom, 5/5 strength.

1/5 of patients will say they are having urinary incontinence. Easy, get a post void. <100cc? Bye Felicia.

I never ask for fever directly. 100% of patients say “well I’d did feel some chills yesterday…” I ask if they are feeling like they are coming down with the flu with fevers, cough, congestion, etc. or measured fevers with a thermometer >100.4 degrees. Of course if they are high risk (IVDU, etc) all bets are off.

I ask men if they are feeling numb by their scrotum. No man wants to admit that unless it’s true. I ask women if it’s numb when they are wiping after they use the restroom. They tend to just be honest about that.

These days I essentially feel like it is standard of care to MRI a high risk elderly vertiginous patient (been burned too many times), but It is rare that I MRI for back pain.

As for steroids, I think this falls under “the art of medicine is amusing the patient until they heal themselves”. Back pain tends to flare up and calm down on its own with time. Everyone is playing the game of giving patients little goodie bags until they fix themselves.

 

[Birdstrike]

Tintinalli's is very clear that if you have classic sciatica with neuro symptoms and without red flags (trauma, fever, cancer, etc) to not do an MRI in the ER. It's even written in BOLD.

Tintinalli is correct on this.

 

[Birdstrike]

I appreciate the pearls outlined above, but is there a definitive way to definitively rule out cauda equina in the setting of severe stenosis without relying on subjective reporting from pts?

Post void residual is very helpful, as someone already mentioned above. If it’s normal, your “I dribbled a little bit one time” isn’t urinary retention. But usually when they see the catheter coming, their pain goes from 10 to an 1, their red-flag symptoms magically get better and they elope.

 

[skougess]

Since we are talking about back pain, my general formula for symptom management to avoid opiates is;

1st visit: lidocaine patch, Toradol, muscle relaxers
2nd visit: medrol dosepak
3rd visit: “I told you that you needed to see @Birdstrike if your pain continued. This is now your fault, I can’t help you in the ED anymore.”

 

[BoardingDoc]

Since we are talking about back pain, my general formula for symptom management to avoid opiates is;

1st visit: lidocaine patch, Toradol, muscle relaxers
2nd visit: medrol dosepak
3rd visit: “I told you that you needed to see @Birdstrike if your pain continued. This is now your fault, I can’t help you in the ED anymore.”

Similar here.
1: Lidoderm, flexaril, recommend NSAIDs.
2: Bump flexaril up to diazepam. Steroids if radicular pain.
3: I don't know why you haven't seen the pain clinic yet. No, you don't get an rx for opioids. If I'm extremely fried and I just want you to go away, you might get a single oral percocet while you're here.
If it really seems like I won't be able to get rid of them (claiming they can't walk due to pain or somesuch) I'll offer to send them to rehab. They still don't get an rx for opioids.

 

[Arcan57]

If I'm worried about infection or malignancy (either known or suspected) or they have objective weakness than they're getting MRI'd. Otherwise, you look at the patient in front of you and say "Would a neurosurgeon take this patient to the OR during this admission?" If the only symptoms are pain and numbness, the answer is going to be no. There's nothing therapeutic about taking a patient with sciatica and making them lay on an MRI table. It's probably going to take narcs or benzos to get them to tolerate the scan. And you know it's going to show mild/moderate/severe foraminal stenosis with mild effacement of the canal at multiple levels. So now you're calling NSGY at 2 in the morning for an MRI you know they're going to do nothing about, and the patient never had a chance of benefitting from anything that happened in the preceding 6 hours.

 

[TooMuchResearch]

I think of numbness/tingling as a potential sign of myelopathy from cord or nerve root compression. I see this frequently, often with normal reflexes, normal strength, normal gait and I usually ask people to stand on heels/toes as part of my back/neck pain exam. If they don't have abnormal findings on those tests, I generally treat conservatively and refer for follow up if no improvement.

You mentioned you don't think of numbness/tingling as a concerning red flag. Is that only when it is confined to a dermatome suggesting nerve root compression as opposed to spinal compression from stenosis or something else? How do you discriminate between these, or what clinical signs or symptoms are you looking for that would prompt you to consult a surgeon?

My average patient with back pain is a red flag and probably can't stand on their toes at baseline.

 

[CajunMedic]

Post void residual is very helpful, as someone already mentioned above. If it’s normal, your “I dribbled a little bit one time” isn’t urinary retention. But usually when they see the catheter coming, their pain goes from 10 to an 1, their red-flag symptoms magically get better and they elope.

I had one of these a couple of shifts ago. Severe L4-L5-S1 disc disease with neurological symptoms at baseline. Shows up with worsening of radiculopathy and incontinence after falling. Sees neurosurgery at big academic medical center down the road. Gets to me 45 minutes after MRI goes home. Called his neurosurgeon to consult and they said that specifically, post-void residuals of less than 200cc are likely not cauda equina.

My treatment plan is like everyone else: Toradol, Robaxin, Lidocaine Patches in the department and prescribed. Steroids if radiculopathic.

 

[Jabbed]

Spinal cord ends at L1. Almost any (non-infectious/oncologic) pathology below this level is never an emergency. Acute cauda equina from chronic spinal stenosis is virtually unheard of.

I CT moderate/high risk (mostly elderly) back pain all the time mainly to r/o malignancy. I would say MRI is only more useful for true motor deficits and epidural abscess r/o in the patient with risk factors and high inflammatory markers. Post-void residual <100 mL is also highly sensitive for ruling out myelopathy.

Pain, paresthesias, and sensory loss in a dermatomal distribution is radiculopathy, not myelopathy, and by definition does not involve the spinal cord. Pain radiating down the legs localizes to L3-S1, which is several levels lower than the termination of the spinal cord. Radiculopathy is a reassuring sign that the spinal cord is probably okay!

 

[Mount Asclepius]

What emergent action are some of you taking when you find vertebral mets? I haven’t found these are an emergency, but perhaps our local practice pattern differs.

 

[Janders]

What emergent action are some of you taking when you find vertebral mets? I haven’t found these are an emergency, but perhaps our local practice pattern differs.

Mostly it is a change in tone from “hey we all get back pain, HTFU and take some meds and see your PCP eventually” to “oh man, we found something…”

I have found Mets / tumor with neuro findings (primarily sensory but maybe subtle strength changes) that get xfer’d for emergent spine/ XRT consultation, but very rarely and they are in the “back pain with red flags and neuro findings” category where you are likely getting some CT/MRI action…

 

[Arcan57]

I had one of these a couple of shifts ago. Severe L4-L5-S1 disc disease with neurological symptoms at baseline. Shows up with worsening of radiculopathy and incontinence after falling. Sees neurosurgery at big academic medical center down the road. Gets to me 45 minutes after MRI goes home. Called his neurosurgeon to consult and they said that specifically, post-void residuals of less than 200cc are likely not cauda equina.

My treatment plan is like everyone else: Toradol, Robaxin, Lidocaine Patches in the department and prescribed. Steroids if radiculopathic.

Incontinence is so non-specific in back pain. The RN triage note always says they have it, but the majority of the time it's baseline or the patient means they can't get to a toilet fast enough due to decreased mobility.

Also, would put in my 2 cents that demonstrating stretching and getting rid of anterior pelvic tilt may help the obviously non-discogenic back pains and give them some tools to prevent bouncing back during subsequent episodes.

 

[dozitgetchahi]

20 years out of training, boarded in EM and Pain Medicine. What you describe is 90% of what I see.

Assuming we are dealing with peripheral nerves, “subjective leg numbness” in a dermatome, in the setting of a nerve root impingement, is not an indication for urgent surgical decompression. I see these all day long and don’t involve a neurosurgeon, on an urgent basis, if ever.

Many of such acute symptoms resolve over a few weeks. If not, then PT/nsaids. If still in pain, epidural steroid injections. If still in pain, then surgical consult.

These play out over weeks to months. Rarely do these immediately get surgery upon the first identification of a disc or osteophyte contacting a nerve root.

Exceptions:

-Acute, objective, motor deficit (eg, foot drop) detectable on exam

-Cauda equine syndrome

-Epidural abscess/discitis/osteomyelitis

-Epidural hematoma

-Cord compression with clinical or radiologic evidence of myelopathy.


If no red flags: Primary care > Interventional Pain > Neurosurgery or Ortho-Spine. Most never get to the surgical end of that pathway.

Rheumatology here - as you might imagine, I see a lot of back pain and I completely agree.

These factors play a role in my back pain “philosophy”:

- In the outpatient setting, you’ll see patients describing back pain with mild LE numbness or weakness all day long. These are very common symptoms.

- Insurance companies usually won’t even think about authorizing an MRI until the patient has done PT.

- Most disc herniations and other simple varieties of LBP get better within 90 days.

- DJD/facet osteoarthritis is also extremely common.

- Osteoporosis is very prevalent in my patient population, so I have a very low threshold for back XRs to r/o vertebral fractures. However, even many types of vertebral fractures aren’t necessarily a medical emergency. I grab XRs on little old ladies all day who I find to have a random L1 compression fracture or whatever…”oh my back has been hurting for years, I had no idea anything like that was back there” etc.

- The only really solid indications for back surgery are massive herniations with lots of cord compression causing incontinence or severe LE weakness, cauda equina syndrome, infectious discitis/osteomyelitis, etc etc etc. However, this represents a tiny fraction of the patients sent to ortho spine and neuro spine surgeons. Most back surgery is done on people with varying degrees of DJD and/or facet arthropathy in the hope that it will relieve pain. However, doctors’ waiting rooms across the country are filled with patients who had back surgery hoping it would alleviate back pain…and it didn’t. (A lot of this surgery happens because it is profitable. But I digress.)

My process is largely PT +/- NSAID, and I usually get XRs to help rule out the compression fx that are quite common among the patients I see. Lidocaine patches are a nice touch too, and some patients find them really helpful. There’s not a lot of evidence that muscle relaxers help, and opioids I avoid altogether for obvious reasons. Steroids? Eh. I don’t relish using corticosteroids in general, and remember that among all its other side effects, 1 Medrol dosepak is enough to cause an AVN (the orthos we worked with in rheum fellowship drilled this into us). If I strike out on that, you’re going to interventional pain mgmt.