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Daily Archives: January 8, 2016

Life-Threatening Lower Back Pain

By |January 8, 2016|Diagnosis, Low Back Pain|

Life-Threatening Lower Back Pain –
Decoding the Mystery Step-By-Step

The Chiro.Org Blog

SOURCE:   A Chiro.Org Contribution

David J Schimp DC, DACNB, DAAPM, FICCN and
Stefanie Krupp DC, MS

David J Schimp DC
Schimp Office of Chiropractic Professionals LTD
937 E. Sumner St.
Hartford, WI 53027 USA

This article will help clinicians identify life-threatening conditions that present with lower back pain.

Intra-abdominal bleed (e.g. aortic aneurysm), infection and tumor are the most dangerous causes of lower back pain and carry the potential for devastating consequences.

Table 1 identifies red flags that should raise suspicion
of a serious disorder. [1]

Other red flags that are less likely to be associated with a life-threatening condition but that still warrant prompt diagnosis and appropriate management include:

  • pain that is worse with coughing
  • incontinence of bowel or bladder
  • urinary retention (inability to void or empty the bladder completely)
  • impotence
  • saddle anesthesia
  • intractable radicular pain into the lower extremity
  • rapidly progressive neurological deficit

The latter findings are common among patients with lumbar nerve root compression or cauda equina syndrome. Although serious, these disorders are seldom life threatening.

Step 1 –   Evaluate for Red Flags*
Table 1:   Red Flags of Low Back Pain   [1]

1.   Duration greater than 6 weeks
2.   Age less than 18y
3.   Age greater than 50y
4.   Prior history of cancer
5.   Fever, chills or night sweats
6.   Weight loss (unexplained)
7.   IV drug use
8.   Recent surgical procedure
9.   Night pain
10.   Unremitting, constant, no relief
11.   Concomitant abdominal pain
12.   Lightheaded, weak, diaphoretic, disorientated

*   This is a list of red flags that may be associated with a
life-threatening disease.

It is not meant to include all the other red flags of lower back pain.

Step 1:   Evaluate for Red Flags   (Discussion)

  1. Duration greater than 6 weeks.   Intractable or progressive lower back pain lasting longer than 6 weeks should raise suspicion of a serious underlying condition. Radiographs (lumbar plain film series including coronal, sagittal and spot views) and routine laboratory studies will add a greater level of diagnostic accuracy to the evaluation. Basic laboratory studies to consider include comprehensive metabolic panel, complete blood count (CBC), C-reactive protein(CRP) or high sensitivity CRP (preferred), erythrocyte sedimentation rate (ESR) and urinalysis (UA). [2]

    If imaging and lab studies are normal and the patient has normal vitals, then serious disease is unlikely. Advanced imaging (MRI or CT) can be utilized if plain film radiography if felt to lack sensitivity. In the absence of serious disease, a mechanical lesion, central sensitization or psychosocial co-morbidities may explain on-going pain over 6 weeks in duration.

  2. Age less than 18 years.   Persistent pain in a pediatric patient is a red flag for tumor or infection if symptoms cannot be ascribed to a congenital abnormality or acute injury. Advanced imaging (MRI) and routine laboratory studies as noted above should be considered.

  3. Age greater than 50 years.   Although low back pain is common in this population, clinicians should be particularly alert to the patient that presents with a new onset of low back pain, whether or not a mechanical basis is identified. Intra-abdominal disorders (e.g. abdominal aortic aneurysm) and cancer are more common in this population. Although a mechanical lesion is more likely, older patients require a greater level of diligence to rule out serious disease.
    see Table 1)

  4. Patient history of cancer.   Neoplasm involving the spine may present as unrelenting pain (i.e. does not improve with rest or analgesia) or pain that is worse at night. Cancer recurrence or metastasis to the spine should be considered when a patient with a prior history of cancer complains of unrelenting back pain. Advanced imaging (MRI) is valuable and early use may be appropriate if the index of suspicion is high. Basic laboratory testing can be helpful (e.g., elevation of alkaline phosphatase on a comprehensive metabolic panel and leukocytosis on a complete blood count). [2] A history of prior malignancy is the most informative of the all the red flags listed in Table 1 and may suggest active neoplasm as the cause of the individual’s back pain.