Thoracic and Lumbar Spine



Thoracic and Lumbar Spine


Lauren M. Post

Angela Hua



CLINICAL CHALLENGE

In the emergency department (ED), low back pain is one of the most common musculoskeletal chief complaints and affects approximately 80% of adults at some point in their lives.1 The complaint of low back pain was responsible for approximately 4% of ED visits from 2000 to 2016.2 “Spinal conditions,” which include neck and back pain, comprise the third largest portion of total national health spending in the United States, behind diabetes and heart disease.3 The majority of patients presenting to the ED will complain of neck or lower back pain rather than thoracic-level pain. Thoracic back pain has been documented less frequently, with < 20% of people reporting symptoms within their lifetime.4 Many will have benign etiologies that will resolve with conservative management, but the small percentage that requires immediate intervention must be quickly identified. In addition, patients with nonemergent conditions require a well-thought out strategic plan to manage their condition and maximize function.

A broad differential diagnosis and an evaluation that is systematic without bias is fundamental to managing low back pain; see Table 14.1. In addition to primary spinal pathology, processes that may refer pain to the back must be considered. Failure to address these alternative diagnoses in the face of localized pain is a common oversight in many case reviews.5 Because of the lower frequency of thoracic back pain, vascular emergencies and other causes of referred pain must remain high on the differential for patients with this complaint.




PREHOSPITAL CONSIDERATIONS

When the emergency medical system is activated, the prehospital provider becomes the first point of triage, with the mechanism of injury determining the initial resources and the transport destination. Traumatic injuries require a rapid primary survey, with an evaluation for the presence of additional injuries and mechanical stabilization of potential fractures. These patients may require
immobilization and log-roll precautions to prevent any further complications. Patients with concomitant head injuries or meeting trauma activation criteria should be transported to a facility with appropriate specialty coverage. Because the etiology of atraumatic back pain is varied, a more comprehensive secondary survey may be needed to determine stability. Abnormal vital signs or motor deficits can provide important information before arrival at the receiving ED, and also guiding further evaluation. It is also critical that the prehospital provider attempt to obtain additional medical history, medications, and alcohol or substance use.






LABORATORY AND DIAGNOSTIC STUDIES

Laboratory testing, in cases of low back pain, is usually not helpful in most patients. Urine pregnancy testing should be considered in all appropriate patients both to facilitate any imaging and to evaluate for an intra-abdominal cause of the pain. Urinalysis can be used to support a clinical decision of renal colic or pyelonephritis as a source of referred pain. If infection or malignancy is suspected, a complete blood count (CBC), erythrocyte sedimentation rate (ESR), and blood cultures may be indicated. Anticoagulated patients and those in whom intervention may be necessary should have a coagulation profile and blood bank typing performed. See the Evidence section for further discussion of the utility of laboratory tests.

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Jun 23, 2022 | Posted by in EMERGENCY MEDICINE | Comments Off on Thoracic and Lumbar Spine
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