Suspect the presence of an infection or malignancy in patients with low back pain who experience unexplained weight loss, nighttime pain, or pain at rest. Matthew Sikina, MD, PGY3, emergency medicine resident, Rowan University Cooper School of Medicine The patient is a 57-year-old woman with a history of long-term tobacco use, hypothyroidism, osteopenia, and a remote history of intravenous drug use (IVDU) who presents with worsening low back pain for three days. He states that the back pain started after tripping and falling at work. Pain worsens with movement and doesn't radiate.
You have been taking over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs) without significant relief. Denies bowel or bladder dysfunction or anesthesia with a saddle. He said the pain has made it increasingly difficult for him to walk, but he denies bilateral weakness or numbness in his lower extremities. It also denies any infectious symptom.
She notes that she has a remote history of IVDU, but that she has been sober for 20 years. He works as a restaurant manager. She denies any significant surgical or family history. On examination, spinal tenderness is observed in the T12 region without obvious bone defects or bone distensions. The motor and sensory exam is five out of five in your bilateral lower extremities, but the pain worsens with movement.
He limps when he walks, but otherwise his gait seems inconspicuous. Lifting your straight leg is normal and you have no abdominal tenderness. The rest of your exam has nothing of special. Low back pain is one of the main common complaints of patients who go to the emergency department.
1 While more than 90% of the non-specific causes of low back pain resolve automatically within four to six weeks, there are serious conditions that can often be overlooked at the initial presentation. 2 Therefore, it is vital that doctors identify risk factors (warning signs) based on a detailed review of the systems and a thorough physical examination. Based on the patient's history of falls and spinal tenderness, you request an X-ray showing an acute T12 compression fracture. A subsequent CT scan shows the absence of ligament injury or spinal cord involvement.
Pain control is achieved with intramuscular ketorolac, a lidocaine patch and a nasal spray of calcitonin. Spinal surgery is consulted and non-surgical management is recommended. The patient is instructed to follow up with her primary care physician and spine surgeon, and their understanding is approved. False clues for treating serious spinal pathology may include spinal stenosis, lower limb edema, nerve root compression, peripheral neuropathy, cervical myelopathy, alcoholism, diabetes, multiple sclerosis, and UMND.
Because of the abundance of false clues that can be presented, it is important for the therapist to interpret the warning signs in the context of the patient's current condition and not in isolation. Back pain is incredibly common and, in many cases, doesn't indicate a worrisome medical problem, but there are some signs that indicate that it may be due to something serious. Back pain that worsens at night, for example, may be a sign of cancer. A fever that accompanies new back pain may be a sign of an infection.
Age, numbness and incontinence are also warning signs to consider when evaluating the cause of back pain. The role of physical therapists in identifying warning signs has changed as physical therapists increasingly become a patient's first point of contact with a healthcare professional. It is difficult to get an exact idea of the epidemiology of warning signs, since it depends to a large extent on the level of documentation of doctors.
