Emergency Medicine

BACK PAIN

332 Musculoskeletal and Soft-tissue Emergencies

MANAGEMENT

1 Refer any patient with features of a central disc prolapse causing any signs of

cauda equina compression immediately to the orthopaedic team. It is an

orthopaedic emergency.

(i) Arrange urgent MRI to best demonstrate the cauda equina (or

any spinal cord) compression.

2 Also refer a patient who has signs of nerve-root compression and or is

completely unable to move, or those who fail a trial of mobilization within

the ED, particularly if living alone or elderly.

3 Discharge patients wit h moderate pain and wit h no ner ve root signs.

(i) Give the patient a non-steroidal anti-inflammatory analgesic

such as ibuprofen 200–400 mg orally t.d.s. or naproxen 250 mg

orally t.d.s.

(ii) Encourage early return to ordinary activities within the limits of

the pain. Bed rest should be kept to an absolute minimum.

(iii) Request review and follow-up by a physiotherapist or the GP

for back-care education including correct posture, safe lifting

techniques and abdominal (transversus abdominis) and back

exercises.

Severe or atypical, non-traumatic back pain

DIAGNOSIS

1 The aim in particular is to exclude a potentially serious underlying path-

ologica l cause. ‘Red f lags’ suggesting t his possibilit y include:

(i) Unexplained weight loss, a history of cancer,

immunosuppression, use of steroids, intravenous drug abuse.

(ii) Fever/sweats, pain at night, duration over 6 weeks and focal,

progressive or disabling symptoms.

2 Causes will vary according to the patient’s age:

(i) <30 years:

(a) ankylosing spondylitis

(b) rheumatoid arthritis

(c) osteomyelitis

(d) discitis

(e) extradural abscess.

(ii) >30 years:

(a) bony metastases

(b) myeloma

(c) lymphoma

(d) renal or pancreatic disease

(e) aortic aneurysm.