What is the initial workup and management for a patient presenting to the emergency department (ED) with low back pain and midline lumbar tenderness after a lifting injury?

Emergency Department Workup for Low Back Pain with Midline Lumbar Tenderness After Lifting Injury

For patients presenting to the emergency department with low back pain and midline lumbar tenderness after a lifting injury, a focused history and physical examination should be performed to classify the pain into one of three categories: nonspecific low back pain, back pain with radiculopathy/spinal stenosis, or back pain with specific spinal pathology, with routine imaging NOT recommended for uncomplicated cases. 1, 2

Initial Assessment

• Conduct a focused history and physical examination to identify any red flags that would require immediate imaging or specialist referral 1, 2:

  • Cauda equina syndrome (saddle anesthesia, bowel/bladder dysfunction)
  • History of cancer with potential bone metastasis
  • Unexplained weight loss or fever suggesting infection
  • Significant trauma or history of osteoporosis suggesting fracture
  • Progressive or severe neurologic deficits

• Assess for midline tenderness specifically, which may indicate:

  • Vertebral compression fracture (especially in patients with osteoporosis or steroid use) 1
  • Possible vertebral infection (if accompanied by fever, recent infection) 1
  • Nonspecific muscular strain (most common in lifting injuries) 3

• Evaluate for radicular symptoms through neurological examination:

  • Lower extremity strength, sensation, and reflexes
  • Straight leg raise test for radiculopathy 1

Diagnostic Testing

• Do not routinely obtain imaging for patients with nonspecific low back pain, even with midline tenderness, if no red flags are present 1, 2

• Consider plain radiography only for:

  • Patients with risk factors for vertebral compression fracture (history of osteoporosis, steroid use) 1
  • Persistent symptoms after 4-6 weeks of conservative management 2, 4

• Order MRI (preferred) or CT immediately only if:

  • Severe or progressive neurologic deficits are present 1
  • Cauda equina syndrome is suspected 1, 5
  • Serious underlying condition is suspected based on history and examination (cancer, infection) 1

• Laboratory testing is generally not required for acute low back pain after lifting injury unless infection or systemic disease is suspected 3

Management Approach

• For nonspecific low back pain with midline tenderness after lifting injury:

  • Recommend maintaining activity within pain limits rather than strict bed rest 2
  • Prescribe first-line medications: acetaminophen or NSAIDs 2
  • Avoid systemic corticosteroids as they have not shown greater effectiveness than placebo 2
  • Avoid opioids for long-term management 2

• For patients with concerning features:

  • If cauda equina syndrome or severe neurologic deficit is suspected, obtain urgent MRI and neurosurgical consultation 1, 5
  • If fracture is suspected, obtain appropriate imaging based on risk factors 1

Follow-up Recommendations

• Reevaluate patients with persistent, unimproved symptoms after 1 month 1

• Consider earlier reassessment for:

  • Older patients
  • Patients with signs of radiculopathy or spinal stenosis
  • Worsening symptoms 1

• If symptoms persist beyond 4-6 weeks despite conservative management:

  • Consider imaging if not previously performed 2, 4
  • Consider referral for physical therapy or more intensive rehabilitation 2

Common Pitfalls to Avoid

• Ordering routine imaging for uncomplicated acute low back pain, which exposes patients to unnecessary radiation without clinical benefit 1, 2
• Referring for inappropriate imaging modality (e.g., plain radiography for suspected cauda equina syndrome instead of MRI) 5
• Failing to assess for psychosocial factors that may contribute to delayed recovery 2
• Prescribing prolonged bed rest, which can worsen outcomes 2
• Overreliance on opioid medications for pain management 2