What is the prehospital assessment and management of a patient with back pain?

Prehospital Paramedic Assessment of Back Pain

The prehospital assessment of back pain should include a focused history and physical examination to categorize patients into one of three groups: nonspecific low back pain, back pain with radiculopathy or spinal stenosis, or back pain associated with a specific spinal cause, which guides subsequent management decisions. 1

Initial Assessment

History Taking

• Obtain information about pain characteristics: location (localized to back, radiating to extremities), frequency (constant, intermittent), duration, and intensity 1, 2
• Document previous episodes, treatments tried, and response to treatments 2
• Screen for serious underlying conditions requiring prompt evaluation (red flags):
  • History of cancer (positive likelihood ratio 14.7) 1, 2
  • Unexplained weight loss (positive likelihood ratio 2.7) 2
  • Failure to improve after 1 month (positive likelihood ratio 3.0) 2
  • Age older than 50 years (positive likelihood ratio 2.7) 2
  • Fever or recent infection 1, 2
  • Significant trauma 1, 2
  • Rapidly progressive or severe neurologic deficits 1, 2
  • Bladder or bowel dysfunction (cauda equina syndrome) 1, 2
• Assess for neurological symptoms: radiating leg pain (sciatica), motor weakness, and pseudoclaudication 2
• Screen for psychosocial factors that predict risk for chronic disabling back pain 1, 2
• Consider non-spinal causes of back pain (pancreatitis, nephrolithiasis, aortic aneurysm) 2

Physical Examination

• Vital signs: temperature, heart rate, blood pressure, respiratory rate, oxygen saturation 1
• Inspect the back for deformities, bruising, or visible abnormalities 1
• Palpate the spine for tenderness, muscle spasm, or step-offs 1
• Assess range of motion (flexion, extension, lateral bending, rotation) 1
• Perform neurological examination:
  • Motor strength in lower extremities 1, 2
  • Sensory testing in dermatomes 1, 2
  • Deep tendon reflexes 1, 2
  • Straight leg raise test for radiculopathy 1
• Check for saddle anesthesia and rectal tone if cauda equina syndrome is suspected 1, 2

Diagnostic Categorization

Based on history and physical examination, categorize patients into one of three groups:

1. Nonspecific low back pain (85% of cases)

   • Localized pain without specific identifiable cause 1, 2
   • No concerning features for serious pathology 2

2. Back pain with radiculopathy or spinal stenosis

   • Radicular symptoms (sciatica) 1, 2
   • Neurological deficits corresponding to nerve root involvement 2

3. Back pain with specific spinal cause

   • Cancer (0.7% of cases) 2
   • Compression fracture (4%) 2
   • Spinal infection (0.01%) 2
   • Ankylosing spondylitis (0.3-5%) 2
   • Cauda equina syndrome (0.04%) 2

Spinal Immobilization Decision

• Immobilize the spine early in any traumatized patient suspected of spinal cord injury to limit the onset or aggravation of neurological deficit 3
• For suspected cervical spinal cord injury, use manual in-line stabilization combined with removal of the anterior part of the cervical collar during tracheal intubation procedures 3
• Follow the algorithm for spinal immobilization:
  • If life emergency exists with quick extraction needed, maintain head-neck-chest stabilization with rigid neck brace 3
  • If pain from spinal process or focal neurological deficiency is present, provide rigid immobilization 3
  • If disturbance of consciousness, alcohol, or distractive pain is present, use rigid plan with neck stabilization (head fixing) and vacuum mattress transport 3

Pain Management

• For moderate to severe pain, consider intranasal fentanyl for patients without intravenous access, especially in pediatric patients 4
• If IV access is established, consider:
  • IV NSAIDs over IV acetaminophen 4
  • Either IV ketamine or IV opioids based on patient presentation 4
  • Either IV fentanyl or IV morphine based on patient presentation 4
• For oral administration, consider either oral acetaminophen or oral NSAIDs 4
• Implement multimodal analgesia combining non-opioid analgesics and muscle relaxants to control pain and reduce muscle spasm 5
• Consider heat therapy to relax tense muscles 5
• For pediatric patients, use age-appropriate distraction techniques to reduce anxiety and pain perception 3

Transport Considerations

• Transport patients with red flags or severe neurological deficits to facilities with appropriate specialty care 1
• Position patient comfortably during transport to minimize pain 5
• Continue monitoring vital signs and neurological status during transport 1
• For patients with suspected spinal cord injury, maintain mean arterial blood pressure above 90 mmHg and keep blood glucose levels within normal range 6

Common Pitfalls to Avoid

• Failing to recognize red flags that may indicate serious underlying conditions requiring urgent attention 1
• Overreliance on opioids for pain management without considering risks 1
• Not assessing psychosocial factors that may contribute to pain perception 1, 2
• Inadequate immobilization in cases of suspected spinal cord injury 3
• Undertreatment of pain, particularly in pediatric patients 3

By following this structured assessment approach, paramedics can effectively evaluate and manage patients with back pain in the prehospital setting, ensuring appropriate care and timely transport to definitive care when needed.