Episode 206: Acute Back Pain

We discuss the evaluation of and treatment options for acute back pain.
Hosts:
Benjamin Friedman, MD
Brian Gilberti, MD



https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acute_Back_Pain.mp3



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Tags: Musculoskeletal, Orthopaedics





Show Notes
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Clinical Evaluation:

* Primary Goal: Distinguish benign musculoskeletal pain from serious pathology.
* Red Flags: Look for indicators of spinal infection, spinal bleed, or space-occupying lesions (e.g., tumors, large herniated discs).
* Assessment: A thorough history and neurological exam (strength testing, gait) is essential.
* Additional Tools: Use bedside ultrasound for post-void residual assessment in suspected cauda equina syndrome

Imaging Guidelines:

* Routine Imaging: Generally not indicated for young, healthy patients without red flags.
* ACEP Recommendations: Avoid lumbar X-rays in patients under 50 without risk factors, as they do not change management and may increase costs and ED time.
* Advanced Imaging: Reserve MRI for patients with red flags, neurological deficits, or suspected cauda equina syndrome; CRP may be a part of your calculus when evaluating for infectious causes of back pain

Treatment Options:

* Evidence-Based First-Line:

* NSAIDs offer modest benefit.
* Skeletal muscle relaxants can be used but require caution due to side effects.


* Ineffective Therapies:

* Acetaminophen shows no benefit for back pain.
* Steroids are not recommended for non-radicular pain, with only limited benefit in sciatica.
* Topical treatments, lidocaine patches, and opioids are not supported by evidence and may pose additional risks.



Alternative and Experimental Interventions:

* Nerve Blocks: Current evidence is limited; more research is needed on trigger point injections and erector spinae plane blocks.
* Severe Pain Management:

* A single opioid dose (preferably codeine or oral morphine) may be considered to facilitate discharge when necessary.
* Use diazepam sparingly for immediate mobilization.
* Onsite physical therapy in the ED can be beneficial when available.


* Preventing Chronic Pain:

* Research Focus: Ongoing studies are evaluating whether duloxetine (Cymbalta) can prevent the transition from acute to chronic back pain.
* Non-Pharmacologic Measures: Consider spinal mobilization, physical therapy, acupuncture, and cognitive behavioral therapy (CBT) as adjuncts in management.



Take-Home Points: