Evaluation and Management of Acute Right Upper Back Pain Near Surgical Scar
This patient requires immediate evaluation for potential complications related to her prior abscess, including recurrent infection or abscess formation, given the location near a previous surgical site and the severity of pain. 1, 2
Immediate Red Flag Assessment
This patient presents with several concerning features that warrant urgent evaluation:
- History of prior right axillary/chest wall abscess with surgical drainage - pain at the surgical scar site raises concern for recurrent infection, abscess, or post-surgical complications 3
- Severe pain (8/10, reaching 10/10) - unrelenting severe pain is a red flag requiring prompt evaluation 1
- Adrenal insufficiency - this patient is at risk for adrenal crisis, particularly in the setting of acute illness or infection, which can present with severe back pain 4
- Pain triggered by lifting heavy objects - while this suggests musculoskeletal etiology, the location near a prior surgical site and severity require ruling out serious pathology first 1, 2
Recommended Diagnostic Workup
Obtain MRI of the thoracic spine without and with IV contrast as the initial imaging study to evaluate for:
- Recurrent abscess or infection near the prior surgical site 3
- Epidural abscess or spinal infection 3
- Post-surgical complications including scarring or nerve entrapment 3
The ACR Appropriateness Criteria specifically recommend MRI without and with IV contrast when there is clinical suspicion of infection or inflammation in patients with back pain and prior surgery 3. This is superior to CT for soft tissue evaluation and can identify early infection before it progresses 3.
Laboratory evaluation should include:
- Complete blood count, erythrocyte sedimentation rate, and C-reactive protein to assess for infection 5, 6
- Blood cultures if fever develops 5
- Morning cortisol level given her adrenal insufficiency and risk of crisis 4
Acute Pain Management
While awaiting imaging results:
- NSAIDs are first-line pharmacologic therapy - they provide approximately 10 points greater pain relief on a 100-point visual analogue scale compared to acetaminophen 1, 7
- Short-term opioid therapy is appropriate given the severity of pain (8-10/10) that is uncontrolled by her home Percocet 2, 7
- Avoid systemic corticosteroids for pain management, as they are ineffective for back pain and could mask signs of infection 3, 1
Critical Considerations for This Patient
Adrenal insufficiency management:
- Ensure she is taking her maintenance glucocorticoid replacement 4
- Consider stress-dose steroids if infection is confirmed, as acute illness can precipitate adrenal crisis 4
- Monitor for signs of adrenal crisis (hypotension, cardiovascular collapse) which can occur even with appropriate replacement 4
Common pitfall to avoid: Do not assume this is simple musculoskeletal pain despite the history of lifting heavy objects. The combination of prior abscess at the same location, severe unrelenting pain, and scheduled breast imaging (suggesting ongoing concern for pathology) mandates ruling out serious underlying conditions before attributing symptoms to mechanical strain 1, 2.
Disposition and Follow-Up
- Admit for observation if imaging shows any evidence of infection, abscess, or if pain remains uncontrolled 5
- Urgent surgical consultation if abscess or epidural infection is identified 5
- If imaging is negative for serious pathology, transition to outpatient management with NSAIDs, activity modification, and close follow-up within 1-2 weeks 2, 6
- Reassess within 24-48 hours if discharged, given the severity of symptoms and risk factors 2
The key distinction here is that while most acute back pain is benign and self-limited 1, 6, this patient's history of prior infection at the exact location of current pain, combined with severe symptoms and underlying adrenal insufficiency, places her in a higher-risk category requiring immediate imaging rather than conservative management 3, 1, 5.