The Case

A 49-year-old man presents to the emergency department with an acute onset of back pain. He was carrying some heavy groceries and felt something pull in his lower back. He took some naproxen, which he uses as needed for an old high school football injury, but is still in pain. You do not find any red flags on the history and physical examination. He is feeling better after a dose of morphine, but he still has difficulty bending and walking. It’s time to consider what medications to discharge him home with.

Background

There are about 2.7 million visits to the emergency department annually for low back pain. While the vast majority of visits are due to benign conditions, this diagnosis can be frustrating for patients and physicians.

One thing physicians have to consider is not missing the uncommon but dangerous conditions like spinal epidural abscess, osteomyelitis, cauda equina syndrome, and pathological fractures. Multiple red flag lists have been published to help physicians identify patients at risk for some of these serious conditions (eg, TUNA FISH, see Table 1). While no list is complete, they can be helpful.

(click for larger image) Table 1: Red Flag Symptoms of Back Pain

Patient demands for imaging can be another source of frustration. The ACEP Choosing Wisely recommendation encourages physicians to avoid lumbar spine imaging:

Avoid lumbar spine imaging in the emergency department for adults with non-traumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition (such as vertebral infection, cauda equina syndrome, or cancer with bony metastasis).

An additional frustration is the lack of efficacious treatments for low back pain. Acetaminophen has been shown not to affect recovery time compared to placebo.¹ Adding cyclobenzaprine or oxycodone/acetaminophen to naproxen alone was shown not to improve functional outcomes.²

There are also concerns about the appropriate use of opioids. ACEP has a clinical policy on prescribing opioids and specifically addresses ED patients with acute low back pain.³ It gives three Level C recommendations:

For the patient being discharged from the emergency department with acute low back pain, the emergency physician should ascertain whether nonopioid analgesics and nonpharmacologic therapies will be adequate for initial pain management.

Given a lack of demonstrated evidence of superior efficacy of either opioid or nonopioid analgesics and the individual and community risks associated with opioid use, misuse, and abuse, opioids should be reserved for more severe pain or pain refractory to other analgesics rather than routinely prescribed.