In a patient complaining of back pain, what are the “red flags” on history that suggest a need for urgent surgical intervention? What historical features suggest an underlying medical cause for the pain (such as a tumor, infection or an inflammatory problem)?
Surgical emergencies in patients presenting with back pain include the cauda equina syndrome (usually due to a tumor or massive disc herniation) and aortic aneurysmal dissection or rupture.
Historical features that should raise suspicion of these conditions include:
- Numbness (particularly “saddle anesthesia”)
- Focal weakness
- Progressive neurological compromise in the lower extremities
- Bladder or bowel incontinence
- Complaints suggestive of heart failure or ischemia (aortic aneurysm)
An underlying medical cause for back pain is suggested by the following features:
- Weight loss
- Known history of malignancy
- Recent infection
- Intravenous drug use
- Night pain
Inflammatory back pain is more likely to occur in patients with IBD, psoriasis or uveitis. The following 5 questions are particularly useful in assessing patients for inflammatory back pain. The presence of four of these five features provide a sensitivity of 0.95 and a specificity of 0.85 for spondylitis:
- Presence of morning stiffness
- Improvement of pain with exercise
- Onset before age 40
- Insidious onset
- Duration of symptoms longer than three months
Do not forget to consider visceral causes of back pain, such as pancreatitis, pyelonephritis, renal colic, or a penetrating duodenal ulcer.