Back pain resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Hilda Mahmoudi M.D., M.P.H.^[2]

Overview

Back pain is pain felt in the back that may originate from the muscles, nerves, bones, joints or other structures in the spine.

Causes

Life Threatening Causes

• Abdominal aortic aneurysm

• Adrenal hemorrhage

• Aortic dissection

• Arachnoiditis

• Cauda equina syndrome

• Cervical fracture

• Chronic stable angina

• Epidural abscess

• Pulmonary embolism

• Retroperitoneal hematoma

• Traumatic aortic rupture

• Vertebral fractures

Common Causes

• Abnormal posturing
• Degenerative disc disease
• Depression
• Discopathy
• Osteoarthritis
• Pregnancy
• Premenstrual syndrome
• Sciatica
• Spinal disc herniation
• Spinal stenosis
• Trauma

Management

Back pain

Sciatica present?

Yes

No

Acute radiculopathy with urinary retention, saddle anesthesia and bilateral neurologic findings AND/OR Progressive motor weakness

Age less than 50 Y/O AND Simple back pain AND No systemic disease or cancer?

Yes

No

Yes

No

Proper spinal immobilization Urgent CT or MRI to evaluate cauda equina syndrome Urgent neurosurgical or neurologic consultation

Order plain film of vertebra Order ESR and/or CRP if you suspicious of osteomyelitis

Consider musculoskeletal back pain Provide back pain conservative treatment for 4-6 weeks

Plain film and ESR/CRP both normal?

Patient improved?

Yes

No

Yes

No

Provide back pain conservative treatment for 4-6 weeks unless neurological deficit is progressive

Consider CT or MRI High clinical suspicious in patient with cancer and new back pain High clinical suspicious in febrile patient with IUD and back pain Close follow up

Consider systemic causes Order plain film of vertebra, order ESR and/orCRP

Patient improved?

Plain film and ESR/CRP both normal?

Yes

No

Yes

No

Reassure patient Advise to stay active Prescribe medication for pain if necessary Discourage bed rest

Consider CT or MRI High clinical suspicious in patient with cancer and new back pain High clinical suspicious in febrile patient with IUD and back pain Close follow up