Non-Traumatic Lower Back Pain

Most of us will have lower back pain in our lives (80–90% lifetime prevalence) and it accounts for 2–3% of ED visits (so quite a bit).

As with everything in EM, there are benign and serious causes and we need to differentiate between the two. The serious causes include diagnoses in the back and those in the abdomen or retroperitoneum.

  • Benign: muscular and ligament strain, sciatica (posterolateral disk herniation) and spinal stenosis
  • Serious back: cancer, spinal epidural abscess, vertebral osteomyelitis, infectious diskitis, spinal epidural hematoma and giant (central) disk hernation (cauda equina syndrome).
  • Serious non-back: AAA, renal stones, renal infarct, tumor, pancreatitis, pancreatic cancer, PUD, cholecystitis, retroperitoneal hemorrhage, psoas abscess

RED FLAGS FOR BACK PAIN

Be sure to document a good history and physical.

  • History
    • Epidural abscess: ***no fever, ***not immunocompromised, ***no IVDA, ***no known h/o bacteremia
    • Epidural tumor: ***no history of systemic cancer or weight loss
    • Epidural hematoma: ***no recent anticoagulation or recent spinal anesthesia
    • Fracture: ***not older age (> 55), ***no prolonged steroid use, ***no trauma, ***no abrasion/contusion to back
    • General: ***no new frequent falls or ataxia, ***no 3 wk of midline pain, ***no nocturnal pain, ***no sphincter incontinence or urinary urgency, ***no bilateral leg symptoms

 

  • Physical examination
    • Motor: ***no weakness in legs (or arms)
    • Sensory: ***no sensory level or saddle anesthesia
    • Reflexes: ***no diminished or hyperreflexic reflexes in the
      • knee
      • ankle
      • Babinski sign (abnormal/upward)
    • Sphincter dysfunction: ***no lax rectal tone (rectal optional but perform in intermediate or high risk patients)
    • Post void residual: ***no more than > 100 cc’s (if urinary symptoms)

 

Given the above, the patient would be classified as

  • HIGH RISK: Hx and PE red flags
  • MED RISK: Hx but no PE red flags
  • LOW RISK: no Hx or PE red flags

 

Testing

Lab testing is rarely useful. WBC, bands and percentage of neutrophils can all be normal in patients with spinal epidural abscess. Though ESR and CRP are non-specific, if normal they can help rule out infectious causes. Normal inflammatory markers don’t rule out disk herniation or epidural hematoma, though.

Imaging of the back should be carefully ordered. X-rays are of no value (if no trauma). MRI’s increased cost. Order these in high risk patients. You can get an outpatient MRI in medium risk patients (talk with the PMD, neurology or surgery to get follow-up, though).

If no further work up is required, discharge the patient home with pain medications and set their expectations.

Discharge Instructions for Low Back Strain

Provide proper instructions to patients who are sent home with lower back pain. First, they should have their expectations properly set. Second, more serious causes of back pain can present insidiously. The patient should know to return if things worsen.

You have been diagnosed with a lumbosacral back strain. This pain can often last 4–6 weeks, but should improve with proper care.

  • Application of heat can be minimally helpful (10 minutes on and 20 minutes off to prevent burns).
  • Bed rest should be of short duration (about 2 days) to hasten recovery.
  • Exercise is not recommended until your symptoms are completely better, but you should resume your normal daily activities.
  • Motrin 800 mg by mouth three-times a day with food for pain. You can take Norco for pain not relieved with Motrin. Muscle relaxants are helpful if there is a significant degree of spasm. These latter two medications can make you sleepy so avoid the use of heavy machinery, driving or complex decision making while on these medications.
  • It is very important you follow up with your primary care doctor in 1–2 weeks.
  • While our most likely suspicion for the cause of your back pain is a lumbosacral strain, more serious causes can initially present similarly. Therefore, return immediately if you develop any of the following symptoms:
    • Numbness or weakness or arms or legs
    • Increasing pain
    • Inability to go to the bathroom normally
    • Numbness in the perineum (“the crotch”)

 

Serious causes of back pain

Spinal Epidural Abscess (SEA)

This has been increasing in incidence due to more diabetes, IVDA, immunosuppressants and invasive spinal procedures. The traditional triad (back pain + fever + neurologic symptoms) is, of course, often absent. The most common finding is severe, unrelenting back pain. If they have such severe pain and a risk factor, you should really consider SEA and order an MRI of the entire spine with and without gadolinium.

Treatment usually consists of antibiotics and surgical decompression, but in those without neurologic symptoms some considering waiting on surgery. Let the surgeon make that call. Consult the neurosurgeon, regardless.

Epidural Tumors

Again the presenting symptoms is unrelenting back pain. Look also for weakness and UMNL (hyperreflexia – probably best to check the knee and ankle). By the time you get bowel and bladder dysfunction, it is too late. Sometimes they don’t have a known primary tumor and this is the first presentation of the cancer. The tumor often presents in any part of the spine.

  • Thoracic 60%
  • Lumbosacral 30%
  • Cervical 10%

The primary sources are from lung, breast and multiple myeloma. But non-Hodgkins lymphoma often presents with extramural spinal cord compression, as well.

Treatment is chemotherapy, radiation and surgery. Call the oncologist and surgeon. Steroids can also be used, so discuss with the consultants.

Spinal Epidural Hematoma

The main risk factors are a recent spinal instrumentation (though in one study, none of the OB epidurals caused a SEH) or use of anti-coagulants in a patient with back pain. Sometimes a venous hemorrhage can occur from an increase in abdominal or thoracic pressure resulting in an spontaneous SEH in the anti-coagulated patient.

Patients present with severe back or neck pain, radiculopathy and neurologic symptoms.

They will likely need surgical decompression and most likely anti-coagulant reversal. Call the neurosurgeon!

Giant Lumbar Disk Herniation

Central disk herniation (33%–75% antero-posterior hernation) is different from sciatica (smaller postero-lateral herniation) and results in cauda equina syndrome. This can be provoked by minimal trauma (like twisting, heavy labor) or the trauma may be absent.

Indications for surgery include cauda equina syndrome, progressive motor deficits or intolerable symptoms.

References

  • Singleton J, Edlow J. “Acute Nontraumatic Back Pain Risk Stratification, Emergency Department Management, and Review of Serious Pathologies.” EM Clinics of North America. 2016
Non-Traumatic Lower Back Pain

Graham-Cassidy Bill Doesn’t Add Up

The latest Republican health care bill meant to replace the Affordable Care act comes from Senators Bill Cassidy (LA) and Lindsey Graham (SC). This one presents a more substantial change to the way things are run. Most of this comes from an article in the 9/23/2017 issue of the Economist.

  • The Federal government would play a much smaller role, giving money to the states proportional to the number of inhabitants between 50% and 138% of the Federal Poverty Level.
  • The decisions on how to structure care is passed down to the states. They can petition Health and Human Services to drop ObamaCare provisions such as the Essential Health Benefits that were meant to provide a basal level of care in each plan.

The thought is that this may encourage experimentation in each of the states, however three problems exist.

  1. States are now responsible for structuring care. There is no guarantee they can do a better job. States are also required to have a balanced budget, so the Medicare money may go instead to paying other debts.
  2. There is no increase in money if conditions change. If a state is hit with a disaster, say an opiate epidemic, and requires more money to address this… there is no more money.
  3. Doesn’t fix existing problems with the health insurance marketplace. Premiums have already risen under the ACA and insurers are leaving markets. This new plan has the potential of further raising premium prices (with healthy people leaving the market without the pressure of a mandate) and discouraging insurers from participating (with less healthy people, they are taking more risk).
Graham-Cassidy Bill Doesn’t Add Up

My Email Rules

Email consumes hours upon hours stealing opportunities to do real work. Several people have devised plans to reclaim this time, so I stole the ones that work for me.

These rules have two goals: to respect my time and that of the receiver.

1. Keep as short as possible.

“I’m sorry to write you a long letter, as I did not have time to write a short one.”

Mark Twain

Invest a little of time upfront to ensure the reader can spend as little time as possible dealing with your email. Re-read and edit harshly. Aim for FiveSentenc.es or FourSentenc.es or Three or Two.

2. Answer in batches.

Process emails at set times (9 am, 4 pm and 9 pm) leaving the rest of the day open for deep work. Many emails work themselves out before I get to them without my interference.

Turn off notifications. Email is not instant messenging. It’s meant to be asynchronous.

During this batch processing, collect all replies to the same person to be sent in one email. Use the iPad’s Split Screen with Drafts and Mail to collect all the responses in Drafts, then send from there.

3. Don’t send work emails on the weekend (or in the night).

Save your nights for sleeping and weekends for rejuvenating.

Plus sending email at odd hours might set the expectation you expect a response. If nights and weekends are the times you can go through email, Airmail (and other programs) have “Send later” features that let you compose at night and send in the morning.

4. Don’t expect immediate replies.

If you’re not responding immediately, don’t expect others to do the same.

5. Aim to close the loop.

Avoid emails volleys that bounce back and forth yet go nowhere.

  • → “let’s have coffee?”
  • “great, when are you free?”
  • → “how about 2?”
  • “no good, have a meeting. Three?”

Provide enough information so both the receiver and I can be done with the issue. Offer some options “Let’s have coffee. I’m free Monday at noon, Tuesday at 4 pm or Thursday at 10 am. If none of these work, call me and we’ll figure out a time.”

If more information is needed, don’t send a placeholder “I’ll get back to you with this info.” Postpone sending the email until I have the information to send.

If there are more than 5-6 back and forth messages, just call/message/slack the person.

6. Everything doesn’t automatically warrant a response.

Don’t jump on the “Congratulations” email chain when someone blast emails a group about a new promotion. And don’t feel guilty about not responding. Sending “Congrats!” is literally the least you could do. If you did any less, you’d be doing nothing. Congratulate them in person instead. That will be much more meaningful.

7. Reply to the minimum people necessary.

Don’t use reply-all unless it’s absolutely necessary. Eliminate any CC’s and BCC’s unless they’re needed. You’re doing them a favor.

8. Make the subject as informative as possible.

A subject of “FYI” means nothing, but “FYI: TPS reports you asked for, no response back needed” is much more informative. If I can fit the whole email in the subject line, even better: “SUBJECT: I’m free for coffee Monday at noon. See you there.”

9. Get rid of quotes

Unless these are needed for context, just delete the pages of nested quotes.

10. Minimize attachments

Don’t send graphics as signatures. Don’t send text in an attachment (Word) that could have easily been included in the body of the email.

11. The best email is the one not sent

Enough said on that one.

References

  1. http://five.sentenc.es
  2. http://www.emailcharter.org
  3. http://calnewport.com/books/deep-work/
My Email Rules