Back Pain

Back pain is a common reason for seeking medical evaluation in the United States and is one of the top five most common emergency department (ED) chief complaints. Nearly 90% of patients who present with atraumatic back pain ultimately have no clear etiology for their discomfort and experience varying degrees of pain relief within 4 to 6 weeks irrespective of therapy.

Acute back pain complaints

However, approximately 2% of acute back pain complaints are attribute to life and/or function threatening processes. The role of the physician is to identify those with emergent etiologies that require urgent interventions from those with benign causes. The provider should also be aware of the evidence and recommendations surrounding the treatment options for non traumatic low back pain.

Neck pain is also a common chief complaint in U.S. adults, but occurs less frequently than lower back pain and is not associate with the same degree of physical disability, decrease productivity/income loss, and health care expenditure as that attribute to back pain. There are several high-risk diagnoses in each system that must be consider when distinguishing between patients who can be safely discharge from the ED.

Hence with conservative treatment and those who require more comprehensive diagnostic evaluation. A complete neurologic exam is require, and abnormal findings such as Horner’s syndrome; so extremity sensorimotor deficits, gait disturbance, hyperreflexia; also Babinski sign all contribute important information to narrowing the differential diagnosis. Maneuvers specific to individual diagnoses are discuss below.

Paresthesias occurring with neck flexion

Shock-like paresthesias occurring with neck flexion (Lhermitte’s phenomenon); so suggests compression of the cervical cord by a midline disc herniation or spondylosis; but may also be a sign of intramedullary pathology such as focal demyelination. Patients with narrow spinal canals may experience focal symptoms; hence similar to those associate with compressive lesions; so such as upper extremity sensorimotor deficits, as well as bladder incontinence and ataxia.
Similar to acute, atraumatic back pain, routine imaging is not indicate for patients; so who present with symptoms of cervical strain in the context of a normal neurologic exam. Specific imaging modalities are discuss below with specific indications for each. Although imaging is not necessary in most meningitis evaluations; so there are several specific instances where it should be considered.
Per current Infectious Disease Society for America (IDSA) guidelines; so a non contrast CT brain study be obtaine prior to lumbar puncture when there is concern for immuno compromise states; hence history of structural CNS disease, new onset seizure, papilledema, alter mental status, or a focal neurological deficit. The priority is to identify patients with a mass lesion or other potential cause of increase intracranial pressure.