Rheumatology Question 10 Instructor

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:

  • Fever
  • Weight loss
  • Known history of malignancy
  • Recent infection
  • Immunosuppression
  • 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.

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