Back Pain

Back pain – or what I call “the human condition.”

If you get through this life having never suffered back pain, consider yourself blessed. I myself wrestle with it about 2-3 times a year, usually from doing something stupid in sports, but a bag of Home Depot cement can lay me out just as well.

When patients come to the ER with back pain, they’re typically miserable, and time spent in the waiting room or lying on stretchers generally doesn’t help. Our goal in caring for these people is to rule out life threats and to take the edge off the pain. Nobody goes home ecstatic, but we hope they at least leave comforted.

Red Flags:

• Cancer … Metastasis or pathologic fracture?
• IV drug use … Epidural abscess?
• Osteoporosis … Fracture?
• Elderly +/- light headed … Aortic aneurysm?
• Fever … Pyelonephritis or infected kidney stone?
• Short of breath … Pneumonia or pulmonary embolus?
• Can’t walk or move lower limbs … Transverse myelitis?
• Urinary/bowel incontinence/retention +/- “saddle numbness” … Cauda Equina Syndrome?
• Lost feeling in my leg … Herniated disc?
• Falls from the second floor or higher onto feet … Associated spine fracture?
• Car accident with lost sensation or strength … Fracture + cord compression?
• “Launched from my four-wheeler and got a sand enema at the Pismo Dunes.”

Happy Words

• “This has happened before.”
• “I was curling in the gym and all of a sudden my back went out.”
• “I have chronic back pain and ran out of my meds.”
• “I can stand up from sitting easily.”
• “I’m pregnant.”
• “I’m constipated.”
• “Whenever it cracks I’m much better.”
• “Ibuprofen does the trick.”
• “The bones don’t hurt. It’s more the muscles on the sides.”

Patients often strongly desire X-Rays, but very rarely are spine X-Rays helpful. They pick up fractures, but miss injuries to ligaments, tendons, muscles, nerves, organs. They also provide a pretty big dose of radiation to the pelvic organs. CT scans may be offered because they’re much better at catching minor fractures, dilated kidneys, kidney stones, and even those rare dilated aortas, cancers, gall stones, pneumonias or pulmonary emboli from left field. Unfortunately, CTs also offer a radiation wallop.

Really the best study is the MRI. But sadly, this is available only on occasion during daytime hours from most ERs. I suspect this will change in the coming years as MRIs get faster and less expensive.

As for pain management, after I’ve scanned for red flags, I very often palpate for one point of maximum pain on the back. If we’re lucky, we find something. I then offer to inject 10-20 cc of bupivacaine which is an anesthetic that helps to take the edge off for 6-12 hours (could be shorter or longer, but much longer than lidocaine.) I’ve been told by a pain management doc that just the act of putting a needle into a spasmed muscle can relieve spasm. And that alone can break the pain-spasm cycle. However, I’ve never tried it because, frankly, the needle is there and the medicine is too. Plus I want the relief to last.

If we knock out the pain completely following local injection, then we’re even more reassured that the pain is not from a fracture or other life threat, and it is likely to resolve with basic TLC + ibuprofen. Actually, I put that on my list of happy words – “Got better with local anesthetic.”

Some people swear by muscle relaxants like Soma, Norflex or Flexeril. Some insist on narcotics like Vicodin or Percocet. I try to stick with ibuprofen (always with food), because it’s anti-inflammatory as well.

There’s my ER perspective. As for Pre-R, just give us a call from your favorite couch. We’ll come by with some bupivacaine and ibuprofen. We can talk about red flags, massage, stretches, warm or cold packs, Salonpas patches, and then perhaps organize an outpatient MRI at your leisure. We’ll also work to find you a good PT. Or a chiropractor if you prefer. Surgery generally won’t be considered until you have that MRI, and we’re happy to help you find a good surgeon as well.

Rest assured, you’re not alone.

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