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Podcast Recap | CPSolvers: Dx - Progressive back pain

May 31, 2024

About 2% of ED visits are for back pain. In this episode of "Clinical Problem Solvers - Dx - Progressive Back Pain - Episode 333," Dr. Reza Manesh and Dr. Rabih Geha who were co-residents at UCSF, bring their passion for clinical reasoning as they as they cover an overall approach to lower back pain, including red flags to consider in the evaluation of two patient cases.

Dr. Reza Manesh graduated from the University of Pittsburgh School of Medicine and completed internal medicine residency at UCSF. He works as a hospitalist, primarily taking care of patients with medical students and residents.

Dr. Rabih Geha attended Boston College and then Brown for medical school. He completed residency and chief residency at UCSF. Rabih splits his time between the ED and inpatient teaching wards.

Podcast length: 38 min.

Patient Cases

• Patient 1 - 72-year-old woman; she's able to walk and does not have too much pain sitting down; vital signs NL; no fever, chills, weight loss; patient reports back pain her whole life, but last couple of weeks it's been "really really hurting in my lower back.” Patient says pain worsened with gardening, chores, and over-exertion. Patient given 15 mg IM Toradol (ketorolac) for pain relief and feels much better. Patient discharged.
• Patient 2 - A 54-year-old man walks in with back pain. He reports pain for the last 10 years, specifically pointing to pain in his thoracic spine. He's been a paraglider and had some rough landings. Over the last month his pain has gotten much worse and reduced his functional capacity. He’s been taking ibuprofen for relief, but can't tolerate the pain anymore. No fever, no chills, no weakness. Patient given 15 mg IM Toradol (ketorolac). Palpatation and percussion are normal. Because sensitivity of x-ray for compression fractures is only about 60%, a CT scan of patient's thoracic spine is obtained to r/o spinal fracture. Diagnosis from CT scan: Diffuse idiopathic skeletal hyperostosis (DISH).

5 Key Takeaways:

1. The majority of patients who present with back pain—95% or more—will experience improvement over time, as did Patient 1.

2. Prioritizing any "red-hot" red-flag symptoms vs. "lukewarm" red-flag symptoms helps clinicians with accurate diagnosing. A focal neurologic deficit is a major red-flag symptom that requires immediate attention to preserve neural function. Other red-flag symptoms are more "lukewarm" red-flag symptoms but should nonetheless cause clinicians to act quickly, including:

• Signs of inflammation. Can appear in the form of weight loss, fever, an abnormal lab like a leukocytosis or elevated ESR. In the case of a spinal epidural abscess – more than half of patients actually don’t have fever, rather it's back pain and a high ESR that points to that diagnostic possibility.
• Hx of cancer.
• Sudden onset of back pain. Sudden onset can mean a disc or vertebral fracture or some kind of vascular problem like a spinal infarct, all situations that should cause clinicians to act quickly.
• Non-lumbar back pain.

In these 2 patient cases, however, there were no red flags. Instead, key differences between Patient 1 and 2 were that Patient 2 was not improving and also had specific pain in his thoracic spine.

3. In practice, there are 4 categories that patients fall into when evaluating low back pain:

• Non-specific, improving. 90% of cases of low back pain are probably related to the muscular system (eg, muscle strain, disc, bone, ligament). Characterized as back pain NOS, the majority get better within weeks or months. A huge clue is acute onset – less than 6 weeks.
• Secondary cause. Another 5% to 7% of patients have a secondary cause like spinal stenosis or spondyloarthritis or a chronic, progressive cause like diffuse idiopathic skeletal hyperostosis (DISH) or epidural lipomatosis (SEL). Patient 2 was eventually diagnosed with DISH.
• Severe causes. Less than 1% of patients who present to primary care have more severe causes. For example, cord compression or Cauda equina syndrome (CES) often will first present with back pain; patients will likely present with motor and sensory symptoms; bowel and bladder symptoms typically happen later in the disease course.
• Non-spinal back pain. This is actually referred pain from the retroperitoneal organs, like the aorta or kidney.

4. Other possibilities to consider and r/o are infection, cancer, and compression fractures:

• Infection. Infections can present with just back pain and no fever, so consider obtaining ESR and CRP in patients with risk factors for bacteremia (eg, hx of IV drug use, HD catheter, recent procedure). If percussing the back reveals no tenderness, it lessens the likelihood of vertebral osteomyelitis.
• Cancer, either active or recently treated. The spine is one of the most common sites to which cancer spreads, including prostate, kidney, breast, lung, and thyroid cancers. Although not everyone who has cancer and comes in with low back pain warrants an MRI, clinicians should have a low threshold to scan if there's sudden onset or severe pain.
• Compression fractures. This primarily applies to anyone with trauma or older patients with osteoporotic risk factors, like glucocorticoid use.

5. A key question then becomes "Who gets imaging?" Actually, the majority of patients presenting with low back pain do not warrant imaging.

Nonetheless, in certain cases, imaging IS warranted. Patient 2 was diagnosed with DISH based on CT.

In cases where imaging for back pain is needed, the three options are X-ray, CT, or MRI. An X-ray may show a fracture. If bone abnormality is a concern, then a CT may be most useful. Otherwise, obtain an MRI, but factor in that it takes time to get an MRI.

Any views, thoughts, and opinions expressed in this podcast recap are solely that of the hosts and guest and do not reflect the views, opinions, policies, or position of epocrates and athenahealth.

Source:

Manesh, Reza and Geha, Rabih (Hosts). (2024, May 7). Clinical Problem Solvers. Dx. Episode 333 - RLR. Progressive back pain. [Audio podcast episode]. https://clinicalproblemsolving.com/2024/05/07/episode-333-rlr-progressive-back-pain/