Emergency Medicine Forum

A 45 y/o female presents with back pain for two weeks. She was helping her sister move, carrying boxes back and forth to a truck, when she suddenly developed severe back pain radiating down her left leg. The pain was so severe she stumbled and fell onto her left side, which made the pain even worse. She stopped carrying boxes, took some Ibuprofen, and laid down, but the pain was persistent and she was having a difficult time ambulating. The pain is constant, worsened by walking, but not relieved with rest. She presented to the ED for evaluation as she is having problems even going to the bathroom as any movement causes significant pain. She has been taking her sisters Vicoden without relief.

ROS: no fevers/chills/ UTI symptoms/bowel or bladder problems/rashes/chest pain/pulmonary complaints/or skin complaints. She had been nauseous since the pain started, and vomited undigested food once.

PMH: G2P2, C-sect x1, s/p Tubal Ligation

SH: no smoking/no drug abuse/social alcohol

FH: negative

PE: WDWN female, lying still on stretcher. Any movement and she winced. 165/95, 110, 98.6F, 22RR, Sat 100%

HEENT, Heart, Lungs, Abdomen all WNL

Rectal Tone: normal

Back: Point tenderness to L3 with L3 distribution of pain down leg.

Positive pain at 30 degrees on straight leg rise.

Motor difficult to test as limited by pain, but focal testing grossly normal. Reflex’s symmetric.  Sensation preserved.

Questions:

1. Should you do an x-ray? Can you list 10 indications for radiographic imaging (sometimes referred to as ‘red flags’)?

According to the American college of Radiography, who published the national guideline clearing house “ACR Appropriateness Criteria for Low Back Pain (1), the following are red flags (indications of a more complicated status that requires imaging):

1. Traumatic injury
2. Unexplained Weight Loss
3. Unexplained Fever
4. Immunosuppression
5. History of Cancer
6. IV drug use
7. Prolonged use of steroids or probable  osteoporosis
8. Age>70yrs (note some experts recommend < 20 or >50)
9. Focal Neurologic Deficit with progressive or disabling symptoms
10. Duration longer than 6 weeks
11. (Some experts also advocate x-rays for those with pain at rest)(2)  

2. What serious diseases can be missed on plain radiograph imaging in patients with complaints of low back pain?

Radiographs can miss some fractures, some types of cancer, and you may not see osteomyelitis. Epidural abscess or non-skeletal causes for back pain (AAA or renal stone or pyelonephritis) can also be missed.

3. What are the three most likely sources of cancer lesions identified on x-rays? What are the most common locations for metastatic bone cancer?

The types of cancers most likely to have mets to the bones (these cancers account for 80% of all metastatic lesions) are: In Women breast (70% of all bone mets in women) and lung cancer, and in men it is prostate (accounting for 60% of all bone mets in men) and lung.(3)  Prostate cancer mets are usually blastic, breast is mixed, and lung is predominantly lytic.(3)

The most common locations, in order of frequency, are: Spine, Pelvis, Ribs, and Proximal Limb Girdles (humorous and femur).(3)

Metastatic disease is unlikely distil to the knees and elbows.(3)

4. Is there any evidence that spinal manipulative therapy (chiropractic treatment) works for low back pain?

Well as it turns out there is a Cochrane meta-analysis of effectiveness of spinal manipulative therapy that was published in 2003. They reviewed 39 Randomized controlled trials, and found spinal manipulation therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy exercises or back school.  This was for both acute and chronic back pain.(4) Interestingly, it didn’t do worse than conventional treatment.

Outcome:
Due to the significant pain at rest, I did elect to obtain x-rays. Additionally, further questioning revealed a 10 lb wt loss in past 3 weeks. X-ray showed compression deformity at L3 with several lytic lesions.  Radiology suggested skull x-ray which supported their concern regarding Multiple Myeloma. Patient was admitted for pain control and further evaluation of Multiple Myeloma.

Disclosures:

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References:

1. AHRQ US Dept HHS, National guideline Clearinghouse, ACR Appropriateness Criteria for Low Back Pain. Accessed at: http://www.guideline.gov/content.aspx?id=13671#Section420
2. Wheeler AH, Berman SA. Low Back Pain and Sciatica. Medscape May 16, 2011. Accessed at:  http://emedicine.medscape.com/article/1144130-overview#showall
3. Chansky HA, Gellman H. Metastatic Carcinoma, Medscape, June 28, 2011.  Accessed at: http://emedicine.medscape.com/article/1253331-overview#showall
4. Assendelft WJ, Morton SC, Yu El, Sttorp MJ, Shekelle PG. Spinal Manipulative Therapy for Low Back Pain. A Meta-Analysis of Effectiveness Relative to Other Therapies. Ann Intern Med 2003 Jun3;138(11):871-81. Abstract accessed at:  http://www.ncbi.nlm.nih.gov/pubmed/12779297