EM Forum Case #166 "Back Badness"
by Charlene Babcock, MD, FACEP
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A 45 y/o female presents with back pain for
two weeks. She was helping her sister move,
carrying boxes back and forth to a truck,
when she suddenly developed severe back pain
radiating down her left leg. The pain was so
severe she stumbled and fell onto her left
side, which made the pain even worse. She
stopped carrying boxes, took some Ibuprofen,
and laid down, but the pain was persistent
and she was having a difficult time
ambulating. The pain is constant, worsened
by walking, but not relieved with rest. She
presented to the ED for evaluation as she is
having problems even going to the bathroom
as any movement causes significant pain. She
has been taking her sisters Vicoden without
relief.
ROS: no fevers/chills/ UTI symptoms/bowel or
bladder problems/rashes/chest pain/pulmonary
complaints/or skin complaints. She had been
nauseous since the pain started, and vomited
undigested food once.
PMH: G2P2, C-sect x1, s/p Tubal Ligation.
SH: no smoking/no drug abuse/social alcohol.
FH: negative.
PE: WDWN female, lying still on stretcher.
Any movement and she winced. 165/95, 110,
98.6F, 22RR, Sat 100%.
HEENT, Heart, Lungs, Abdomen all WNL
Rectal Tone: normal
Back: Point tenderness to L3 with L3
distribution of pain down leg.
Positive pain at 30 degrees on straight leg rise.
Motor difficult to test as limited by pain, but focal testing grossly normal.
Reflex's symmetric. Sensation preserved.
Questions:
1. Should you do an x-ray? Can you list 10 indications for radiographic imaging
(sometimes referred to as 'red flags')?
2. What serious diseases can be missed on plain radiograph imaging in patients
with complaints of low back pain?
3. What are the three most likely sources of cancer lesions identified on
x-rays? What are the most common locations for metastatic bone cancer?
4. Is there any evidence that spinal manipulative therapy (chiropractic
treatment) works for low back pain?
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