Back pain

Question 1

A 57 year old lady has presented to ED with a lower back pain for 2 weeks. She is unable to walk now. How will you assess this patient?

Answer 1

Impression
This is a red flag presentation of back pain given the progression to now being unable to walk, and as such is a medical emergency demanding immediate assessment and management

Aetiologies to consider;
- MSK: fracture, spondylosis, spondylolisthesis, disc herniation - trauma
- infective: spinal cord abscess, disci tis, osteomyelitis
- degenerative: OA, compression fractures
- Neoplasia: mets, primary bone cancer
Complications to consider;
- spinal cord injury, caudal equina, radiculopathy

Goals:

• Targeted Hx/Ex/Ix, investigate for serious complications
• appropriately disposition patient for appropriate emergent management

Question 2

Back pain - History

Answer 2

History

• Timing, onset, progression. neuro sx apart from weakness? (sensory, parasthesia - distribution) Why can’t walk? pain or weakness?
• MOI, trauma? fragility fractures in past?
• REDS: trauma, unexplained weight loss, neurology, age>55, fevers, immunocompromised, steroids, dual incontinence
• PMHx: diabetes
• Meds, allergies
• SNAP

Question 3

Back pain - Examination

Answer 3

Examination

• General appearance + vitals
• Neuro examination: LL; weakness, tone, reflexes, sensation, assess gait
• MSK: spinal tenderness, deformity, massess, erythema, ROM, bone pain
• PR exam for anal tone (cauda equina)
• Systems review: metastasis

Question 4

Back pain - Investigations

Answer 4

Investigations
Key/Diagnostic
- MRI STAT

• Labs: FBC, UEC, LFT, CRP/ESR, Cultures, CMP, ALP

Question 5

Back pain - Management

Answer 5

Management
Depends on underlying cause
- appropriately disposition by calling neurosurg or med/rad onc teams for referral, involve early in management

Cancer
- dexamethasone in short-term to shrink/reduce mass

Abscess

• drainage
• IV ABx

Fractures/other MSK pathology
- neurosurgeon referral