What is the best approach to evaluate and manage a patient with back pain in the ER?

ER Documentation Template for Back Pain

Chief Complaint

Patient presents with [acute/subacute/chronic] back pain of [duration] located in the [lumbar/thoracic/cervical] region, [with/without] radiation to [location].

History of Present Illness

Pain began [date/timeframe] and is described as [sharp/dull/aching/burning]. Pain intensity is [0-10]/10 on numeric rating scale. Aggravating factors include [activity/position] and relieving factors include [rest/position/medication]. 1 Patient reports [ability/inability] to maintain normal activities. 1

Red flag assessment: Patient [denies/reports] fever, unexplained weight loss, history of cancer, recent infection, significant trauma, urinary retention, fecal incontinence, saddle anesthesia, progressive neurologic deficits, or new-onset bowel/bladder dysfunction. 2, 3 Patient [denies/reports] history of osteoporosis, chronic steroid use, or age >70 years. 2, 4

Psychosocial screening: Patient [denies/reports] depression, job dissatisfaction, catastrophizing thoughts, or fear-avoidance beliefs regarding back pain. 1, 3

Physical Examination

Vital signs: Temperature [value], indicating [absence/presence] of fever as potential infection marker. 2

Musculoskeletal: Midline tenderness [present/absent] over [specific vertebral levels], which [may/does not] suggest vertebral compression fracture or infection. 2 Paraspinal muscle spasm [present/absent]. Range of motion [normal/limited] in [flexion/extension/lateral bending/rotation].

Neurologic examination: 1, 2

• Motor strength: [5/5 or specify deficit] in bilateral lower extremities, testing hip flexion, knee extension, ankle dorsiflexion, and great toe extension
• Sensory: [Intact/diminished] to light touch in [L1-S1] dermatomes bilaterally
• Reflexes: Patellar [2+/diminished/absent] bilaterally, Achilles [2+/diminished/absent] bilaterally
• Straight leg raise: [Negative/positive at ___ degrees] bilaterally, [with/without] reproduction of radicular symptoms
• Gait: [Normal/antalgic/unable to assess]

Assessment

Classification: Patient has [nonspecific low back pain/back pain with radiculopathy or spinal stenosis/back pain with specific spinal cause]. 1, 3 Red flags are [absent/present: specify]. 2, 3

Diagnostic Testing

Imaging: [No imaging obtained as patient has nonspecific low back pain without red flags per American College of Physicians guidelines 1, 2, 3 / Plain radiography ordered due to [age >70, osteoporosis risk, trauma history] / MRI ordered emergently due to [suspected cauda equina syndrome, progressive neurologic deficits, suspected serious underlying condition]]. 2, 3

Laboratory studies: [None indicated / CBC, ESR, CRP obtained due to concern for infection / Additional studies as clinically indicated]. 1

Treatment Plan

Non-pharmacologic management: 1, 2, 3

• Patient counseled to remain active and avoid bed rest, as maintaining activity reduces disability and improves outcomes
• Advised to apply superficial heat using heating pads for short-term symptom relief
• Provided education regarding favorable prognosis, with most acute low back pain improving within 4-6 weeks

Pharmacologic management: 1, 2, 3

• [Acetaminophen up to 4g daily prescribed for mild-to-moderate pain / NSAIDs (specify agent and dose) prescribed as first-line medication / Skeletal muscle relaxant (specify agent) prescribed for muscle spasm]
• Opioids [not prescribed for initial management due to abuse potential and lack of superior efficacy / prescribed only as last resort with careful monitoring]

Disposition and Follow-up

Patient discharged home with instructions to follow up with primary care physician within [1 month if symptoms persist / earlier if symptoms worsen or new red flags develop]. 2, 3 Return precautions provided for development of urinary retention, fecal incontinence, saddle anesthesia, progressive weakness, or worsening pain. 2, 3 Patient instructed that if symptoms persist beyond 4-6 weeks without improvement, reevaluation with consideration of imaging and physical therapy referral will be necessary. 2, 3

[If red flags present: Neurosurgery consulted / Admitted for further evaluation and management / Urgent MRI arranged with close follow-up]. 2