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An Evidence-Based Approach to the Evaluation and Treatment of Low July 2013 An Evidence-Based Approach Volume 15, Number 7 To The Evaluation And Author Pierre Borczuk, MD Assistant Professor of Medicine, Harvard Medical School; Associate in Treatment Of Low Back Pain In Emergency Medicine, Massachusetts General Hospital, Boston, MA Peer Reviewers The Emergency Department Boyd D. Burns, DO, FACEP Associate Professor of Emergency Medicine, Vice Chair of Academic Affairs and Residency Director, University of Oklahoma School of Abstract Community Medicine, Tulsa, OK Gregory L. Henry, MD, FACEP Clinical Professor, Department of Emergency Medicine, University of Low back pain is the most common musculoskeletal complaint Michigan Medical School; CEO, Medical Practice Risk Assessment, that results in a visit to the emergency department, and it is 1 Inc., Ann Arbor, MI of the top 5 most common complaints in emergency medicine. CME Objectives Estimates of annual healthcare expenditures for low back pain in Upon completion of this article, you should be able to: the United States exceed $90 billion annually, not even taking lost 1. Develop an approach to the evaluation of patients with low back pain to differentiate patients who are likely to have benign productivity and business costs into account. This review explores causes of pain from those who will need a medical workup and/ an evidence-based rationale for the evaluation of the patient with or imaging studies. low back pain, and it provides guidance on risk stratification 2. Recognize the red flag signs and symptoms in patients with low pertaining to laboratory assessment and radiologic imaging in the back pain. 3. Assess the neuroanatomy of the lower spine and nerve roots and emergency department. Published guidelines from the American correlate with specific findings on the neurologic examination. College of Physicians and American Pain Society are reviewed, 4. Evaluate the strength of data behind recommendations with emphasis on best evidence for pharmacologic treatments, for treatments for low back pain and identify those that are evidence-based. self-care interventions, and more invasive procedures and surgery in management of low back pain. Utilizing effective and proven Prior to beginning this activity, see the back page for faculty strategies will avoid medical errors, provide better care for pa- disclosures and CME accreditation information tients, and help manage healthcare resources and costs. Editor-In-Chief Nicholas Genes, MD, PhD Keith A. Marill, MD Corey M. Slovis, MD, FACP, FACEP Research Editor Andy Jagoda, MD, FACEP Assistant Professor, Department of Assistant Professor, Harvard Medical Professor and Chair, Department Michael Guthrie, MD Professor and Chair, Department of Emergency Medicine, Icahn School School; Emergency Department of Emergency Medicine, Vanderbilt Emergency Medicine Residency, Emergency Medicine, Icahn School of Medicine at Mount Sinai, New Attending Physician, Massachusetts University Medical Center; Medical Icahn School of Medicine at Mount of Medicine at Mount Sinai, Medical York, NY General Hospital, Boston, MA Director, Nashville Fire Department and Sinai, New York, NY International Airport, Nashville, TN Director, Mount Sinai Hospital, New Michael A. Gibbs, MD, FACEP Charles V. Pollack, Jr., MA, MD, York, NY Professor and Chair, Department FACEP Stephen H. Thomas, MD, MPH International Editors of Emergency Medicine, Carolinas Chairman, Department of Emergency George Kaiser Family Foundation Peter Cameron, MD Associate Editor-In-Chief Medical Center, University of North Medicine, Pennsylvania Hospital, Professor & Chair, Department of Academic Director, The Alfred Kaushal Shah, MD, FACEP Carolina School of Medicine, Chapel University of Pennsylvania Health Emergency Medicine, University of Emergency and Trauma Centre, Associate Professor, Department of Hill, NC System, Philadelphia, PA Oklahoma School of Community Monash University, Melbourne, Emergency Medicine, Icahn School Steven A. Godwin, MD, FACEP Michael S. Radeos, MD, MPH Medicine, Tulsa, OK Australia of Medicine at Mount Sinai, New Professor and Chair, Department Assistant Professor of Emergency York, NY Ron M. Walls, MD Giorgio Carbone, MD of Emergency Medicine, Assistant Medicine, Weill Medical College Professor and Chair, Department of Chief, Department of Emergency Editorial Board Dean, Simulation Education, of Cornell University, New York; Emergency Medicine, Brigham and Medicine Ospedale Gradenigo, University of Florida COM- Research Director, Department of Women’s Hospital, Harvard Medical Torino, Italy William J. Brady, MD Jacksonville, Jacksonville, FL Emergency Medicine, New York School, Boston, MA Professor of Emergency Medicine Hospital Queens, Flushing, New York Amin Antoine Kazzi, MD, FAAEM and Medicine, Chair, Medical Gregory L. Henry, MD, FACEP Scott D. Weingart, MD, FCCM Associate Professor and Vice Chair, Emergency Response Committee, Clinical Professor, Department of Robert L. Rogers, MD, FACEP, Associate Professor of Emergency Department of Emergency Medicine, Medical Director, Emergency Emergency Medicine, University FAAEM, FACP Medicine, Director, Division of University of California, Irvine; Management, University of Virginia of Michigan Medical School; CEO, Assistant Professor of Emergency ED Critical Care, Icahn School of American University, Beirut, Lebanon Medical Center, Charlottesville, VA Medical Practice Risk Assessment, Medicine, The University of Medicine at Mount Sinai, New Inc., Ann Arbor, MI Maryland School of Medicine, York, NY Hugo Peralta, MD Peter DeBlieux, MD Baltimore, MD Chair of Emergency Services, Professor of Clinical Medicine, John M. Howell, MD, FACEP Senior Research Editors Hospital Italiano, Buenos Aires, Interim Public Hospital Director Clinical Professor of Emergency Alfred Sacchetti, MD, FACEP Argentina of Emergency Medicine Services, Medicine, George Washington Assistant Clinical Professor, James Damilini, PharmD, BCPS Dhanadol Rojanasarntikul, MD Emergency Medicine Director of University, Washington, DC; Director Department of Emergency Medicine, Clinical Pharmacist, Emergency Attending Physician, Emergency Faculty and Resident Development, of Academic Affairs, Best Practices, Thomas Jefferson University, Room, St. Joseph’s Hospital and Medicine, King Chulalongkorn Louisiana State University Health Inc, Inova Fairfax Hospital, Falls Philadelphia, PA Medical Center, Phoenix, AZ Memorial Hospital, Thai Red Cross, Science Center, New Orleans, LA Church, VA Robert Schiller, MD Joseph D. Toscano, MD Thailand; Faculty of Medicine, Francis M. Fesmire, MD, FACEP Shkelzen Hoxhaj, MD, MPH, MBA Senior Faculty, Family Medicine and Chairman, Department of Emergency Chulalongkorn University, Thailand Professor and Director of Clinical Chief of Emergency Medicine, Baylor Community Health, Icahn School of Medicine, San Ramon Regional Suzanne Peeters, MD Research, Department of Emergency College of Medicine, Houston, TX Medicine at Mount Sinai, New Medical Center, San Ramon, CA Emergency Medicine Residency Medicine, UT College of Medicine, York, NY Eric Legome, MD Director, Haga Hospital, The Hague, Chattanooga; Director of Chest Pain Chief of Emergency Medicine, Scott Silvers, MD, FACEP The Netherlands Center, Erlanger Medical Center, King’s County Hospital; Professor of Chair, Department of Emergency Chattanooga, TN Clinical Emergency Medicine, SUNY Medicine, Mayo Clinic, Jacksonville, FL Downstate College of Medicine, Brooklyn, NY Case Presentations many elements that constitute how humans feel and interpret pain. Interspersed between the patients A 45-year-old man presents after 7 days of pain in his with musculoskeletal back pain are patients with lower back. He reports that it began the day after he started back pain who are at risk for permanent neurologic at a new job site. The pain initially improved with ibupro- or even life-threatening sequela because they are fen, but he woke up this morning with a severe exacerba- harboring lesions that require timely diagnosis and tion of the pain. He denies a fall or other trauma, and he treatment. By utilizing a focused approach, the ED states that the pain radiates from his left buttock to his left clinician will be able to identify these “red flag” foot. He has had intermittent back pains in the past, but he symptoms in patients and initiate a workup. This is- never required any imaging or interventions. Employed in sue of Emergency Medicine Practice reviews the prog- the construction industry, he has a history of hypertension ress to date on developing a standardized, focused and is going through a divorce. He is afebrile, has a benign approach and guides the clinician to rationally and abdominal exam, and displays an antalgic gait. He has cost-effectively evaluate the patient presenting with intact patella and Achilles reflexes, and he has a positive left low back pain symptoms. straight-leg raise sign and crossed straight-leg raise sign. Strength and sensation, including the perineum, are intact Critical Appraisal Of The Literature and symmetrical. The patient insists that he needs an MRI and requests a note for 2 weeks off from work... The study of low back pain is plagued by the fact that As you are considering your first patient’s requests, a it is not a single pathologic entity. In addition, pain 27-year-old woman is placed in the next room, also com- is a subjective complaint that can be measured only plaining of lower back pain. You review her past visits and indirectly, and these measurements are influenced by see that she has been to the
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