Treating back pain in the ER

[TrailRun]

Hey all,

ER doc starting a pain fellowship next year. Wondering if you have any tips/tricks or nuances I could start implementing in the ER, particularly with respect to low-risk back pain (strain, sciatica). Actually didn't see much in residency (since 10 hour waits were typical) but see a bunch now in the community. Assuming no red flag symptoms, the typical approach amongst my colleagues is NSAIDs, Lidoderm +/- Robaxin/Flexeril/Valium (rarely). X-ray if patient insists (recognizing low utility). Is there a role for something like Gabapentin or similar if they're having radiculopathy? It typically takes 3-4 weeks for patients to get in with the one Pain guy locally. Can't start any meds that require prior auth. Thanks!

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[Ducttape]

no more than 1 day of bedrest.

simple back exercises and stretches to start as early as they are able.

be careful with heating pad.

instruct on warning signs to watch out for.

wouldnt start gaba - you cant give a large enough/long enough script. gaba is more of a chronic pain med.

instead of valium, if less than 60 years old, consider amitriptyline prn at bedtime. make sure they dont take it concurrently with flexeril.

 

[lobelsteve]

No opiates, benzos, or Soma out of the ER.
Zanaflex is sedating
Try any of the AED class, lyrica/gabapentin/topomax/keppra
Try Duloxetine.
Short course of NSAIDs ok.
PO steroids not really helpful unless prior good response.

 

[Agast]

I wouldn’t start amitriptyline in the ER. Takes a long time to start helping, PCP won’t be comfortable continuing it. Could interact with other psych meds they may not tell you they are on.

Stick to methocarbamol and a shot of toradol if kidneys are ok. Advanced imaging would be much appreciated.

 

[SSdoc33]

get an xray.

i dont know how many times patients follow up with me and then i have to do an xray. you find all sorts of stuff. compression fractures. spondylolysis. DDD, etc.

listen to us about back pain treatments, not the internists who develop these ridiculous "guidelines"

 

[RoloTomassi]

I think gabapentin is a good idea. I give it to all acute radics. Less potential for interactions than TCA. Stick with Robaxin for muscle relaxant, it's the least likely to have side effects, interactions. Flexeril is pretty worthless. You can do steroid pack for hot radics. Not much evidence for use but can sometimes help.

 

[callmeanesthesia]

For acute back pain, I’ve been recommending vitamin C (tid to ensure there is adequate absorption) and collagen supplement. Not huge evidence but low risk. There is also some population-level data that subclinical vitamin C deficiency is associated with back pain, and we know from the CRPS literature that it plays some role in healing. Also it lets them feel like they’re taking a medicine 3x a day to help with the pain, while they do exercises.

Collagen Peptides, in Association with Vitamin C, Sodium Hyaluronate, Manganese and Copper, as Part of the Rehabilitation Project in the Treatment of Chronic Low Back Pain - PubMed

The combination of rehabilitation based on McKenzie back exercises and oral viscosupplementation with Fortigel®, Vitamin C, sodium hyaluronate, manganese and copper represents a valid option in patients with chronic LBP, as it ensures pain relief and improvement in the quality of life and in...

pubmed.ncbi.nlm.nih.gov

 

[willabeast]

If I were bad enough to go to an ER with back pain (as in unable to walk) I think I would ask for a one time steroid bolus of some sort. Basically anything to keep me from being admitted and allow me to suffer at home. Not sure which would be worse, being unable to walk or being admitted to a hospital. But there probably is no one solution fits all, and need to make sure no infection(I like stat sed rates).

 

[lobelsteve]

For acute back pain, I’ve been recommending vitamin C (tid to ensure there is adequate absorption) and collagen supplement. Not huge evidence but low risk. There is also some population-level data that subclinical vitamin C deficiency is associated with back pain, and we know from the CRPS literature that it plays some role in healing. Also it lets them feel like they’re taking a medicine 3x a day to help with the pain, while they do exercises.

Collagen Peptides, in Association with Vitamin C, Sodium Hyaluronate, Manganese and Copper, as Part of the Rehabilitation Project in the Treatment of Chronic Low Back Pain - PubMed

The combination of rehabilitation based on McKenzie back exercises and oral viscosupplementation with Fortigel®, Vitamin C, sodium hyaluronate, manganese and copper represents a valid option in patients with chronic LBP, as it ensures pain relief and improvement in the quality of life and in...

pubmed.ncbi.nlm.nih.gov

If you gave me vitamins and minerals for pain, and I’ve already been to the ER, I would laugh out of your office.

 

[doctoroxygen]

Trigger point injections are easy to learn and can speed time to dispo if you talk up how they take awhile to work and it’s best to recover with them in your own home.

Valium is not a pain medication and should not be prescribed for pain for any reason.

My patients don’t find tizanidine to be as sedating as other muscle relaxants for some reason and it’s what I most commonly prescribe. Flexeril seems to be the most poorly tolerated muscle relaxant from this perspective.

 

[SSdoc33]

Trigger point injections are easy to learn and can speed time to dispo if you talk up how they take awhile to work and it’s best to recover with them in your own home.

Valium is not a pain medication and should not be prescribed for pain for any reason.

My patients don’t find tizanidine to be as sedating as other muscle relaxants for some reason and it’s what I most commonly prescribe. Flexeril seems to be the most poorly tolerated muscle relaxant from this perspective.

? WTH?

dont do a TPI for back pain in the ER.

also, dont do a TPI for back pain.

 

[callmeanesthesia]

If you gave me vitamins and minerals for pain, and I’ve already been to the ER, I would laugh out of your office.

Yes but we all know the right answer for acute back pain without red flag findings is “go back to work, you’ll get better.” At least this way they feel like they get a medicine they can take 3 times a day, and you can talk about the role of vitamin C in tissue healing and collagen in the discs, and maybe prevent them from having a bunch of unnecessary treatments and narcotics and time off work for something that was going to get better on its own in a few weeks.

 

[SSdoc33]

If you gave me vitamins and minerals for pain, and I’ve already been to the ER, I would laugh out of your office.

he does practice in california.....

and dont make fun of vitamin C. id does work marginally better than eye of newt......

 

[paindoc503]

Are you guys using SNRI's and TCA's regularly for acute back pain?

 

[hopefulgasman]

Are you guys using SNRI's and TCA's regularly for acute back pain?

No

 

[Ducttape]

not regularly.

but it is a relatively speaking safe drug for those under 60, primarily as an alternative to those insistent on valium or an opioid for acute back pain.

especially if there is going to be some delay before injection may be available.

 

[GoBeers]

in the ED, toradol shot and dexamethasone shot at most.
otherwise send out with nsaid and muscle relaxant and maybe medrol dose pack
no opioids or benzos at all cost unless severe pathology discovered (disc herniation, fracture)

 

[Agast]

Yes but we all know the right answer for acute back pain without red flag findings is “go back to work, you’ll get better.” At least this way they feel like they get a medicine they can take 3 times a day, and you can talk about the role of vitamin C in tissue healing and collagen in the discs, and maybe prevent them from having a bunch of unnecessary treatments and narcotics and time off work for something that was going to get better on its own in a few weeks.

This is probably why medical marijuana is huge in California lol

 

[callmeanesthesia]

he does practice in california.....

and dont make fun of vitamin C. id does work marginally better than eye of newt......

Hey, that’s a good idea too. Eye of newt refers to mustard seed, which apparently has anti-inflammatory effects:

Mustard Seeds (Rai): Uses, Benefits, Side effects, and More By Dr. Rajeev Singh - PharmEasy Blog

There have been recipes of mustard seeds from 5000 years ago that recommend mustard seeds as an appetizer.

pharmeasy.in

(Don’t get too worked up about this, it’s just the first Google link I found).

 

[Baron Samedi]

- Neuro exam
- Plain films
- 3-5 days of meloxicam 15mg if no contraindications
- 500-1000mg acetaminophen tid PRN
- 300mg qhs gabapentin if neuropathic symptoms or patient can't sleep
- Encourage early mobilization and return to work.

 

[DoYouEvenLiftBro]

Why no tpi?

 

[MitchLevi]

A huge percentage of acute LBP is lumbar strain, especially in younger people. TPI is a great option for those people, and I have no clue why anyone would say otherwise. Similarly, dry needling sessions x 3-4 after PT is great. I do TPI frequently, and many pts do well with it. Put a little bit of Toradol in the injectate.

Chronic LBP patient leaves on Thursday for a flight to Colorado, TPI them on Wednesday with Toradol.

 

[Agast]

It has to be a true trigger point

If you poke at a sore muscle you run the risk of making it hurt more

 

[VA Hopeful Dr]

I wouldn’t start amitriptyline in the ER. Takes a long time to start helping, PCP won’t be comfortable continuing it. Could interact with other psych meds they may not tell you they are on.

Stick to methocarbamol and a shot of toradol if kidneys are ok. Advanced imaging would be much appreciated.

Is that actually something you're seeing?

I ask because I write for it all the time and can't imagine being uncomfortable with it unless the patient is on at least 2-3 other serotonergic medications, especially at the doses commonly used for pain.

 

[Baron Samedi]

Is that actually something you're seeing?

I ask because I write for it all the time and can't imagine being uncomfortable with it unless the patient is on at least 2-3 other serotonergic medications, especially at the doses commonly used for pain.

The problem is that the PCP is actually a PCNP.

 

[SSdoc33]

Why no tpi?

Same reason i dont do a rain dance when there’s a drought

 

[cowboydoc]

Same reason i dont do a rain dance when there’s a drought

Now who is a climate change denier?

 

[bedrock]

Same reason i dont do a rain dance when there’s a drought

LOL. patients love a good TPI.

A huge percentage of acute LBP is lumbar strain, especially in younger people. TPI is a great option for those people, and I have no clue why anyone would say otherwise. Similarly, dry needling sessions x 3-4 after PT is great. I do TPI frequently, and many pts do well with it. Put a little bit of Toradol in the injectate.

Chronic LBP patient leaves on Thursday for a flight to Colorado, TPI them on Wednesday with Toradol.

I do the same as Mitch. It’s a great option for someone who needs a bit of pain relief right now. I also do my TPI with Toradol (unless contraindicated) and they are a great way to break the acute pain cycle in a patient that has to wait a couple weeks for their ESI, or who is going a trip in a couple days, etc.

TPI Also helpful for more acute patients that are thinking somewhat about opioids because they don’t trust that an NSAID and lyrica will be enough for their current pain level.

I always mention to the patient that I will include Toradol in the injection because “that’s what ER doctors use for acute migraine and kidney stones” to provide significant pain relief fast.

Patients then generally accept not getting opioids and also accept having to wait a week or two for an ESI.

Finally, I notice a lot of cervical RFA patients will still have significant soreness at the cannulae entry point even 5-6 weeks later.
A cervical TPI with Toradol is very helpful to clear that up. You then have a patient particularly satisfied with final outcome of their cervical RFA.

 

[MitchLevi]

Neuritis should be easily distinguished from procedural soreness.

I'm not sure how often I have pts complain of soreness (rarely), but as I've posted repeatedly across several threads in this forum, post cervical RFA neuritis is something I see at incredibly common rates. I've posted procedural pictures as well.

Hypersensitivity in the shower and the sunburn sensation is what I hear > 95% of the time. Occasionally hear about irritation with clothing too.

If you ablate C2-3 you're virtually guaranteed to get it bc there's quite a bit of cutaneous involvement at that level. If you do C3-4 there's a good chance of it as well.

Way less at C4-T1.

The giant review article posted a year or so listed C2-3 at like over 90% likelihood of causing PAN.

 

[Agast]

Is that actually something you're seeing?

I ask because I write for it all the time and can't imagine being uncomfortable with it unless the patient is on at least 2-3 other serotonergic medications, especially at the doses commonly used for pain.

Patients tell me their PCPs want me to take over their duloxetine, trazodone, TCAs etc

 

[epidural man]

Toradol works as well if you squirt the stuff orally - but still give it in the muscle - seems more invasive for the patient's benefit.

An hour infusion of ketamine, keep the dose low.

I am 100% on board with muscle injections with lidocaine. Most of the ER visits for back pain are spasms to the multifidus or psoas.

If you feel comfortable with ultrasound, do TPI's to the psoas.

Have the ER buy a TENS unit and apply that and make the patient wear it for an hour.

Out the door with Tizanidine.

No opioids ever. Washington state did a great study that says that if the patient is given opioids in the ER on back pain presentation, this predicts an increased likelihood of not returning to work ever (well....at least a year out).

X-ray is easy and reassuring to the patient.

A few times I have gotten an in-pateint consult for an ESI (for acute back pain) and no none examined the patient and they have a hip fracture. Make sure you at least examine the patient. That may be obvious, but in busy ER's, things slip by.

 

[Agast]

Toradol works as well if you squirt the stuff orally - but still give it in the muscle - seems more invasive for the patient's benefit.

An hour infusion of ketamine, keep the dose low.

I am 100% on board with muscle injections with lidocaine. Most of the ER visits for back pain are spasms to the multifidus or psoas.

If you feel comfortable with ultrasound, do TPI's to the psoas.

Have the ER buy a TENS unit and apply that and make the patient wear it for an hour.

Out the door with Tizanidine.

No opioids ever. Washington state did a great study that says that if the patient is given opioids in the ER on back pain presentation, this predicts an increased likelihood of not returning to work ever (well....at least a year out).

X-ray is easy and reassuring to the patient.

A few times I have gotten an in-pateint consult for an ESI (for acute back pain) and no none examined the patient and they have a hip fracture. Make sure you at least examine the patient. That may be obvious, but in busy ER's, things slip by.

How much are you charging for the ketamine infusion?

 

[lobelsteve]

Toradol works as well if you squirt the stuff orally - but still give it in the muscle - seems more invasive for the patient's benefit.

An hour infusion of ketamine, keep the dose low.

I am 100% on board with muscle injections with lidocaine. Most of the ER visits for back pain are spasms to the multifidus or psoas.

If you feel comfortable with ultrasound, do TPI's to the psoas.

Have the ER buy a TENS unit and apply that and make the patient wear it for an hour.

Out the door with Tizanidine.

No opioids ever. Washington state did a great study that says that if the patient is given opioids in the ER on back pain presentation, this predicts an increased likelihood of not returning to work ever (well....at least a year out).

X-ray is easy and reassuring to the patient.

A few times I have gotten an in-pateint consult for an ESI (for acute back pain) and no none examined the patient and they have a hip fracture. Make sure you at least examine the patient. That may be obvious, but in busy ER's, things slip by.

You must be treating other type of humans to see the psoas with US. And then injecting it as a TPI.
It is as deep as a discogram. Unless you are going distal, then you have the viscera or the numerous thingies around and at the inguinal ligament to traverse.

 

[MitchLevi]

Iliopsoas bursa is superficial to the hip joint. Easy injxn.

 

[lobelsteve]

Iliopsoas bursa is superficial to the hip joint. Easy injxn.

I do not think anyone will ever confuse pain from iliopsoas bursa with LBP.
Maybe an L2-3 radic and iliopsoas bursitis.

 

[powermd]

A huge percentage of acute LBP is lumbar strain, especially in younger people. TPI is a great option for those people, and I have no clue why anyone would say otherwise. Similarly, dry needling sessions x 3-4 after PT is great. I do TPI frequently, and many pts do well with it. Put a little bit of Toradol in the injectate.

Chronic LBP patient leaves on Thursday for a flight to Colorado, TPI them on Wednesday with Toradol.

I used to poo poo the idea of TPIs in acute msk pain until I tried one on myself. Six weeks into a calf strain that was only getting worse, I injected the gastroc fascia at the musculotendinous junction of my right calf, pretty much where the pain and spasms were originating. That 30g needle hurt like a MF asian hornet! From that moment on though, it got better. I was able to start running, biking, and lifting again within a week. It's been good ever since.

 

[MitchLevi]

Discogenic hurts in the groin, as does a spondy.

 

[epidural man]

How much are you charging for the ketamine infusion

We do them at no cost to the patient

 

[kstarm]

Patients go to the doctor/ER for a variety of reasons but the frequently it is to know how worried they need to be. Try to address this:

There is nothing dangerous going on with your back that needs surgery at this time, I know it hurts but it isn't dangerous (if appropriate)-This works better after looking at their xray.

They want to know what they can do to make it better or worse:

You will not cause damage to your back by doing regular movement, it might hurt but you won't damage anything. Avoid weight away from your body and twisting while you are in such bad pain ( if concerned about a radic). We know that keeping moving is really important but you need to approach it like Goldilocks. If you don't move at all you will get stiff and more sore, if you push it too hard it will flare up, you need to find just the right amount for you.


They want to know what you are going to do to make it better:

Here is some medications (lots of options already given in this thread) that should help you feel better over the next several days. I also want you to follow-up with Dr. X (what ever your work-flow is for spine follow-up)

Obviously, coach about red flags.

 

[SSdoc33]

Now who is a climate change denier?

touche

 

[SSdoc33]

A huge percentage of acute LBP is lumbar strain, especially in younger people. TPI is a great option for those people, and I have no clue why anyone would say otherwise. Similarly, dry needling sessions x 3-4 after PT is great. I do TPI frequently, and many pts do well with it. Put a little bit of Toradol in the injectate.

Chronic LBP patient leaves on Thursday for a flight to Colorado, TPI them on Wednesday with Toradol.

what are you injecting and where?

trigger point injections are for myofascial pain syndrome. you push on a trigger point in a taut band and the pain radiates.

yes, you CAN inject an acute strain, and the risks are minimal, but your rationale is suspect. what are you hitting? paraspinals? QL? multifidi? you have no idea.

what you are really doing is an intra-muscular toradol injection and that is giving some pain relief. you would get the same relief if you gave it in the deltoid.

id argue that many acute strains are discogenic in nature. the lumbar musculature intimately intertwines with the annulus. those "strains" that last a while are more likely disc.

 

[Dr. Ice]

Just saw a 42 year old woman like this today. Right sided axial pain following a fall. She’s a dancer so flexible, and classic disc pain not quite there although pain with knee flexion to chest. Occasionally radiating to thigh with “pelvic pressure.” I suspect internal disc disruption vs frank herniation. Groin pain was also present, no pain with any movement of hip. No trigger points so didnt inject. She may get an mri outside of insurance cause she really doesn’t need 6 weeks of PT

 

[powermd]

what are you injecting and where?

trigger point injections are for myofascial pain syndrome. you push on a trigger point in a taut band and the pain radiates.

yes, you CAN inject an acute strain, and the risks are minimal, but your rationale is suspect. what are you hitting? paraspinals? QL? multifidi? you have no idea.

what you are really doing is an intra-muscular toradol injection and that is giving some pain relief. you would get the same relief if you gave it in the deltoid.

id argue that many acute strains are discogenic in nature. the lumbar musculature intimately intertwines with the annulus. those "strains" that last a while are more likely disc.

Well, I do all my TPs with ultrasound, so I know exactly what I'm injecting. Generally, it's the lumbar erector fascia, under the lat fascia, in the zone next to the PSIS where the middle cluneal nerve can get entrapped. That's what gives these guys at least 4-6 hours of anesthetic relief. Now some actually improve, but many return to baseline. There's a distinct group where the pain seems to focus lower, at the erector tendon insertions on the sacrum, and if you inject there you will get a diagnostic and sometimes therapeutic effect as well.

 

[mdo1738]

Well, I do all my TPs with ultrasound, so I know exactly what I'm injecting. Generally, it's the lumbar erector fascia, under the lat fascia, in the zone next to the PSIS where the middle cluneal nerve can get entrapped. That's what gives these guys at least 4-6 hours of anesthetic relief. Now some actually improve, but many return to baseline. There's a distinct group where the pain seems to focus lower, at the erector tendon insertions on the sacrum, and if you inject there you will get a diagnostic and sometimes therapeutic effect as well.

4-6 hours is more than enough time to get them out of the ER