Urgent considerations

Your Organizational Guidance

ebpracticenet urges you to prioritize the following organizational guidance:

Klinische richtlijn rond lage rugpijn en radiculaire pijnPublished by: KCELast published: 2018Guide de pratique clinique pour les douleurs lombaires et radiculairesPublished by: KCELast published: 2018
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Suspected infection or tumor causing back pain requires urgent workup. Patients at high risk of a condition requiring urgent investigation include those on immunosuppressive therapies, and those with a history of intravenous drug use.

Red flag signs and symptoms warranting urgent diagnostic imaging and referral to a spine specialist for ongoing management may include:[29][30][31][32][33][34][35][36]​​

  • Saddle anesthesia

  • Sphincter disturbance (bladder or bowel dysfunction e.g. acute urinary retention, new onset urinary or fecal incontinence, loss of anal sphincter tone)

  • Profound or progressive neurologic deficit

  • History of malignancy with new onset back pain

  • Systemic ailments, including fever, chills, night sweats, and/or unexplained weight loss

  • Intravenous drug use

  • Urinary tract infection

  • Immunosuppression, including prolonged corticosteroid use or other immunosuppressive therapies

  • Trauma (including minor trauma in older adults)

  • Presence of contusion or abrasions over the spine

  • History of osteoporosis

  • Pain that is refractory to conservative management

  • Thoracic pain

  • Non-mechanical pain (i.e., systemic or referred causes of pain). Pain at rest and at night suggests a non-mechanical cause.

  • Age >50 years

Red flag signs and symptoms vary between guidelines.[37] Most guidelines endorse the red flags of history of malignancy, unexpected weight loss, significant trauma, prolonged corticosteroid use, fever and HIV.[5][36]​​

One systematic review of observational studies found that the presence of multiple red flags may increase diagnostic accuracy of thoracolumbar pain; the diagnostic accuracy of a single red flag as a self-contained screening tool was low.[36]

Cauda equina syndrome

A presumed diagnosis of cauda equina syndrome necessitates an urgent workup. Bowel or bladder dysfunction, bilateral sciatica, and saddle anesthesia may be symptoms of severe compression of the cauda equina. Signs can include sensory changes in saddle or perianal area, sensory changes or numbness in the lower limbs, lower limb weakness, reduction or loss of reflexes in lower limbs and reduced anal tone.

The etiology is usually a large central herniated disk or a pathologic or traumatic fracture, causing compression of the cauda equina.

A complete history, physical exam and urgent diagnostic imaging should identify impending neurologic compromise and the need for emergent referral to a spinal surgeon.[29]

Spinal cord compression

Spinal cord compression (SCC) can occur as a result of spine trauma, vertebral compression fracture, intervertebral disk herniation, primary or metastatic spinal tumor, or infection. Acute SCC is a medical emergency that requires swift diagnosis and treatment to prevent irreversible spinal cord injury and long-term disability. Clinicians should maintain a high index of suspicion for SCC in patients with a history of malignancy and back pain.

Symptoms and signs depend on the level of spinal cord compression. Patients may report sensory symptoms of altered sensation below a certain level or hemisensory loss; motor symptoms of hemiplegia/hemiparesis, paraplegia/paraparesis or tetraplegia/tetraparesis; and/or autonomic symptoms including constipation and urinary retention. Examination may detect motor weakness, a sensory level and altered reflexes. Hyper-reflexia and loss of pinprick sensation, temperature, position, and vibratory sensation may occur early, especially when associated with malignancy.

Urgent MRI or CT imaging is indicated.[31][38][39]​ ​Treatment of acute spinal cord compression is typically with surgery.[39]​ Corticosteroids and/or radiotherapy may also be used, particularly for spinal cord compression caused by malignancy.[39]​ 

Trauma

CT imaging of the cervical and thoracolumbar spine is the preferred test for patients with midline tenderness, a high energy mechanism of injury, or those who are >60 years with a mechanism of injury consistent with thoracolumbar spine injury.[31]​ CT may also be required in patients who cannot be examined due to intoxication, Glasgow Coma Score <15‚ or a distracting injury.[31] Neurologic compromise, gross spinal deformities or manual step off on spinal palpation also warrant CT.

CT has a higher sensitivity for detecting fractures of the thoracolumbar spine than plain radiographs and also identifies soft tissue injuries that often accompany spinal fractures.[31][40]​​ Imaging of the entire spine is recommended because approximately 20% of patients with spinal fracture have a second noncontiguous fracture.[31]

If plain radiographs are obtained, anteroposterior and lateral views are required. A “swimmer’s lateral” view should be obtained if the shoulders obscure the upper thoracic spine.[31]

Of note, spinal precautions should be taken when moving trauma patients until the spine is cleared by the trauma or spinal surgeon. If any abnormalities are noted on imaging, a spinal surgeon should be consulted for further management.

Epidural abscess

This rare condition is characterized by inflammation with pus within the epidural space.

Risk factors for epidural abscess include diabetes mellitus, intravenous drug use, an immunocompromised state, recent spinal surgery or trauma, presence of indwelling spinal catheter, pre-existing infection (in contiguous tissue or distant infection causing bacteremia), dialysis and alcohol misuse.[27]

Spinal epidural abscess can present with fever, back or neck pain, and neurologic deficits. However, this triad of symptoms is only present in 10% to 15% of cases and therefore having a low threshold for considering this diagnosis in patients at risk is crucial.[27] Back or neck pain is the most common symptom in individuals with spinal epidural abscess, occurring in 70% to 100% of cases.[41] Pain is increased with weight-bearing and not relieved by rest.

Neurologic loss develops rapidly. Patients require urgent investigation with MRI (without and with contrast).[38] The use of an intravenous contrast agent increases lesion conspicuity, and helps to define the extent of the infectious process.[38][42]

For all patients, treatment includes empirical and subsequent culture-directed definitive antibiotic therapy.

For patients with neurologic deficit, decompressive surgery is essential. In these patients, the single most important predictor of the final neurologic outcome is the patient's neurologic status immediately before decompressive surgery.

Acute pancreatitis

Typically presents with sudden-onset mid-epigastric or left upper quadrant abdominal pain, which often radiates to the back (usually the lower thoracic area but can be a band-like wraparound pattern).[43] Classically, the pain is relieved when the patient leans forward. Often there are associated symptoms of nausea and vomiting. Patients may have fever, jaundice, tachycardia and/or tenderness and guarding of the abdomen. Risk factors include gallstones and excessive alcohol intake.

Diagnosis is confirmed by the presence of two of the following:[44]​​

  • abdominal pain consistent with acute pancreatitis,

  • serum lipase or amylase >3 times the upper limit of normal,

  • and/or characteristic findings from abdominal imaging.

Serum lipase and amylase have similar sensitivity and specificity but lipase levels remain elevated for longer (up to 14 days after symptom onset vs. 5 days for amylase), providing a higher likelihood of picking up the diagnosis in patients with a delayed presentation.[44][45]​​​​​​

Assess hemodynamic status and resuscitate the patient with crystalloid intravenous fluids. Use a moderate goal-directed fluid replacement strategy for the best overall patient outcomes; both overly aggressive and overly conservative fluid therapy can cause harm in acute pancreatitis.[46][47]​ Guidelines differ in their specific recommendations; check local protocols.​

Assess for signs of organ dysfunction immediately on presentation, particularly cardiovascular, respiratory, or renal. Systemic inflammatory response syndrome (SIRS) and/or multi-organ failure are the biggest risk to life in the first week. Consider intensive care unit transfer (or transfer to a monitored bed setting) for any patient who has SIRS or early signs of organ failure.[44]​​ Treat pain promptly using a standard "pain ladder" approach.[46] Opioids may be needed for effective pain control.[48]

Ruptured abdominal aortic aneurysm

Patients with the triad of abdominal and/or back pain, pulsatile abdominal mass, and hypotension warrant immediate resuscitation and surgical evaluation as repair offers the only potential cure.[49]

Initiate standard resuscitation measures immediately, including:

  • Airway management (supplemental oxygen and endotracheal intubation and assisted ventilation if the patient is unconscious).

  • Intravenous access (central venous catheter).

  • Arterial catheter; urinary catheter.

  • Hypotensive resuscitation: aggressive fluid replacement may cause dilutional and hypothermic coagulopathy and secondary clot disruption from increased blood flow, increased perfusion pressure, and decreased blood viscosity, thereby exacerbating bleeding. A target systolic BP of 50 to 70 mmHg and withholding fluids is advocated preoperatively.[50]​ The US guidelines recommend permissive hypotension to reduce bleeding.[51]​  However, recommended targets vary and there is no consensus among global guideline groups.[52]

  • Blood product (packed red cells, platelets, and fresh frozen plasma) availability and transfusion for resuscitation, severe anemia, and coagulopathy.

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