Acute Back Pain

Approach to Acute Back Pain Cause of Back Pain Spinal Spinal stenosis Congenital Acquired Degenerative disease Disc herniation Degenerative disc disease (DDD) Facet joint hypertrophy Spinal canal stenosis Foramenal stenosis Spondylolisthesis Systemic disease Osteoporosis Paget's disease Ankylosing spondylitis Spinal tumors Neoplasms Spinal Primary: Hemangioma, breast, kidney, colon Secondary: Metastases Extraspinal Pancreatic malignancy Renal malignancy Infections Spinal epidural abscess Discitis Osteomyelitis Debridement Antibiotics Vascular Spinal cord infarction Aortic dissection Non-Spinal Rib fracture Muscle strain Visceral pain Pancreatitis Cholecystitis Pericarditis Psoas abscess Prostatitis Renal colic Hydronephrosis Aortic dissection Esophageal perforation Esophageal spasm Perforating ulcer Renal colic Hydronephrosis Other Facet arthropathy Costovertebral spondylosis Pyogenic arthritis Rheumatoid arthritis Ankylosing spondylitis Psoriatic arthritis Enthesitis Red Flags Age <18 or >50 years Immunosuppression Cancer history or unexplained weight loss Bacteremia Spinal anesthesia Significant trauma related to age Medications Long-term steroids: Risk of osteoporosis, pathological fracture, spinal infection Anticoagulants: Risk of spinal epidural hematoma IV drugs: Risk of spinal infections Pain doesn't improve with rest Signs of aortic pathology: AAA or aortic dissection Pulse deficits in lower limbs Unequal P measurements in upper extremities Murmur of aortic regurgitation Spinal cord compression syndromes: Cauda equina, conus medullaris syndrome Spasticity, hyperreflexia (UMN) distal to site of compression Flaccid paralysis, hyporeflexia distal to site of compression in spinal shock Lower limb paresthesias or anesthesia (inc. saddle anesthesia) Bowel, bladder, or sexual dysfunction Management Approach Back and lower limb exam Test for meningitis, radiculopathy Assess for perianal sensation and anal tone Lab Findings CBC ESR CRP Vitamin B12 levels HLA-B27 Serum chemistries & amylase & lipase for pts with suspected GIT pathology D-dimer tests for suspected aortic dissection Imaging Indications: Severe or progressive neurological findings Red flag features of underlying malignancy or spinal infection Pain persisting despite at least 4 weeks of conservative management Approach to Imaging in Acute Back Pain Isolated radiculopathy, no red flag features: Urgent imaging typically not required Suspected spinal causes: New or rapidly progressive neurological symptoms: Urgent MRI spine with and without IV contrast Post-void bladder scan to exclude urinary retention Suspected vertebral fracture or ankylosing spondylitis: X-ray spine Suspected nonspinal causes: ECG, ultrasound abdomen Nonspecific back pain: Imaging not routinely required, consider MRI if pain persists for 4-6 weeks Common etiologies Spinal cord compression (%) Conus medullaris and cauda equina syndrome [191 Vertebral fractures |20l Urgent spinal causes of acute back pain l*l Diagnostics (15) Characteristic clinical features • Major risk factor: history of cancer • Clinical features: sudden onset or rapid progression of any of the following • Back pain, radicular pain • Neurological defects below the level of the lesion • Sensory defects • Progressive weakness of the legs • Altered reflexes (initial hyporeflexia; followed by hyperreflexia and extensor plantar response) • Bladder and bowel dysfunction; loss of spincter tone • Features of incomplete cord syndromes (e.g, Brown-Séquard syndrome) 0171 • Preferred initial imaging modality: urgent MRI with or without IV contrast y • Evidence of extrinsic cord compression (e.g. tumor, intervertebral disk herniation, hematoma ( • High signal areas on T2 within the cord, representing acute edema • Alternative: CT myelography, similar findings to MRI • Major risk factor: preexisting degenerative disk disease 5 • Clinical features • Severe low back pain | • Asymmetric, areflexic, flaccid paresis of bilateral legs (cauda equina syndrome) • Symmetric, hyperreflexic paresis of lower limbs (conus medullaris syndrome) • Saddle anesthesia • Urinary retention with overflow incontinence • Fecal incontinence; loss of sphincter tone • Risk factors • Atraumatic (pathological fracture): history of osteoporosis, steroid use, or malignancy • Traumatic: history of injury (may be minor in • Preferred initial imaging modality: urgent MRI lumbar spine without and with IV contrast (14) • Evidence of extrinsic cord compression (intervertebral disk herniation, hematoma, tumor) | • Edema of the cauda equina (high signal intensity on T2) • Alternative: CT lumbar spine without IV contrast or CT myelography (14 • Similar findings to MRI • Hourglass-like constriction due to partial or complete block of contrast (on myelography) | • Bladder scan: may show retention 4 • Laboratory studies • Suspected fragility fractures: serum vitamin D and calcium may be low • Suspected malignancy: See "Bone metastases" under "Nonurgent spinal causes of acute back pain." • Preferred initial imaging modality: x-ray spine (AP and lateral views) (21|141 • Loss of vertebral body height or wedging • Loss of normal contour of the vertebral body with fraaments of bone Acute management • Urgent neurosurgery consult for surgical decompression • Malignant spinal cord compression: high-dose IV steroids (18) • Treatment of the underlying cause (e.g., radiotherapy for metastases, surgical evacuation of abscesses, spine stabilization surgery) • Urinary catheter if the patient has retention • Urgent neurosurgery consult for surgical decompression. • Unstable vertebral fractures or evidence of cord compression • Surgical stabilization of the spine (spondylodesis) • Cord decompression • Stable vertebral fractures with no neurological symptoms or evidence of cord compression Spinal epidural abscess Vertebral osteomyelitis (261 percussion, and compression • Risk factors • Recent bacterial infection • IV drug use • Diabetes • Invasive procedures C • Alcohol use disorder • Immunosuppression • Clinical features • Point tenderness • Fever and rigors • Radicular pain | • Limited spinal cord mobility| • Signs of spinal cord compression • Risk factors • Older patients with comorbidities • Immunocompromise • IV drug use • Clinical features • Insidious onset of pain • Fever 0(26) • Fracture of transverse processes • Alternatives • CT spine without contrast [: similar findings to x- ray 59 • MRI spine without contrast: may help to differentiate types of fractures , and may show spinal cord injury. 59 1221231249 • Laboratory studies • СВС: + WBC C • Inflammatory markers: + CRP, 1 ESR • Culture (blood, sputum, urine, aspirate): may identify the causative pathogen (Staphylococcus aureus in up to 75% of cases). (J (251 • Consider HIV testing in patients with risk factors for bloodborne viruses. • Consider IFN-y release assay in patients with risk factors for tuberculosis. • Lumbar puncture should be avoided. C • Preferred initial imaging modality: urgent MRI with and without IV contrast (14) • Soft tissue mass in epidural space 4 • Rim enhancement surrounding a nonenhancing center • Alternative: CT spine with IV contrast; similar findings to MRI • Laboratory studies • + WBC, 1 CRP, 1 ESR • Blood cultures may identify the underlying pathogen. • Consider IFN-y release assay in patients with risk factors for tuberculosis. • Consider HIV testing in patients with risk factors for bloodborne viruses • Preferred initial imaging modality: MRI spine with IV contrast • Changes to signal intensity in the intervertebral disks and vertebral bodies • Alternatives • CT spine with and without contrast: for patients with contraindications to MRI ! • FDG-PET: in patients with equivocal MRI scans due • Kyphoplasty • For further information, see "Treatment" in "Vertebral fractures. • IV antibiotic therapy • Referral to neurosurgery for consideration of drainage • For further information see "Treatment" in "Spinal infections." • Neurological symptoms or evidence of sepsis: urgent neurosurgery consult and empiric antibiotic therapy • No neurological symptoms; hemodynamically stable: culture-specific IV antibiotics once results are available Common Etiologies of Acute Back Pain Clinical Features Spinal Stenosis Risk factors: Older age, obesity, degenerative changes Clinical features: Pain in buttocks and legs that worsens with walking or standing, relieved by sitting or bending Preferred initial imaging modality: MRI spine without contrast Alternatives: CT myelography if there are contraindications to MRI Intervertebral Disc Herniation Risk factors: Repetitive lifting, smoking, poor posture Clinical features: Unilateral radicular pain (commonly L4/L5 and L5/S1) with positive straight leg raise test Preferred initial imaging modality: MRI spine without contrast Alternatives: CT myelography if there are contraindications to MRI Spondylolisthesis Risk factors: Congenital, degenerative changes secondary to osteoporosis or trauma Clinical features: Pain that worsens with activity, limited spinal mobility, neurological symptoms Preferred initial imaging modality: X-ray of the spine (lateral view) Alternatives: CT or MRI for further evaluation Bone Metastases Risk factors: History of cancer, advanced age Clinical features: Localized spinal pain that may radiate to the shoulder or neck, sudden increase in pain, pathological fractures Preferred initial imaging modality: MRI with and without contrast Additional imaging: CT with and without contrast if primary site is unknown Inflammatory Back Pain Risk factors: Typically occur in adults aged 20-40 years, family history, HLA-B27 positive Clinical features: Insidious onset of pain, mostly at rest or at night, restricted spinal mobility, extra-articular symptoms Preferred initial imaging modality: X-ray sacroiliac joints and lumbar spine Additional imaging: MRI with and without contrast for high signal intensity representing inflammatory changes Treatment Conservative: NSAIDs, physical therapy, epidural steroid injections Surgical: For severe stenosis or intractable pain, vertebral fusion or decompression For further information, see "Treatment of Spinal Stenosis" Laboratory Studies CBC, ESR, CRP Vitamin B12 levels HLA-B27 Serum chemistries & amylase & lipase for patients with suspected GIT pathology D-dimer tests for suspected aortic dissection