Straight, No Chaser: When Back Pain Could Be Life Threatening

Back pain hurts, but there are various causes of that pain that will kill or cripple you.  Here’s some information on some diseases that present with back pain representing life-threats.  Be advised that as an Emergency Physician, my initial orientation is more toward ruling out the life-threatening consideration than making a definitive diagnosis, which comes afterwards.  Forewarned is forearmed.
Let’s start where we left off on post discussion general low back pain and identify what I was talking about….
Here are a few clues to help you hone in on whether your back pain requires emergency attention.  Remember pain and pathology (serious disease) are two different considerations.  I’m describing medical emergencies here and admittedly being overly simplistic.

  • Direct blow to your back:  Think Fracture
    • The trauma literature suggests that most motor vehicle collisions don’t have enough direct force to break your back.  It’s suggested that the force of a baseball bat is needed to break something in your back if you were previously healthy.  That said, the consequences of fracture are such that direct back trauma from a fall or other direct blow are such that you should at least be evaluated.
  • Fever and new onset back pain: Think Spinal Epidural Abscess
    • A spinal epidural abscess is a ‘pus pocket’ (i.e. infection) that collects between the spinal cord’s outer covering and the bones.  It can result from a recent back surgery, a back boil, a bony spinal infection (vertebral osteomyelitis), from IV drug abuse, or as part of an infection otherwise delivered from the blood.  Antibiotics for about a month and/or surgery may be required.
  • Loss of control of your bowel movements or bladder: Think Cauda Equina Syndrome (CES)
    • There are many neurologic causes of low back pain, but the ones associated with ‘hard’ neurologic findings represent true medical emergencies.  CES is caused by something compressing on the spinal nerve roots, like a ruptured lumbar disk, a tumor, infection, bleeding or fracture or various birth defects.  This could lead to loss of bowel and bladder control and possibly permanent paralysis of your legs.  Again, there are several other causes of these symptoms, but for the purposes of this blog, get evaluated quickly, and let us figure out whether this or something else is going on.
  • New onset back pain after age 65: Think Cancer
    • There are several considerations in play when it comes to back pain in the elderly, including fractures and arthritis, but the life-threatening consideration I’m focusing on is cancer.  The spine is a common place for cancer cells to metastasize; in fact approximately 70% of patients with metastatic cancer will have spinal involvement.  Given that only about 10% of these patients tend to be initially symptomatic, it’s imperative that you get evaluated if symptoms present.  It could represent a significant advancement of disease.
  • Numbness and tingling in both of your legs: see Cauda Equina Syndrome above
  • Night-time back pain: Think Metastatic Cancer.
    • Bone pain at night in a patient previously diagnosed with cancer is the most ominous symptom in patient with metastatic cancer, that which spreads throughout the body.
  • Sudden sexual dysfunction: See Cauda Equina Syndrome above
  • Weakness and/or loss of motion or sensation in your legs: See Cauda Equina Syndrome above
  • Unexplained new weight loss and new onset back pain: Think Cancer
    • There are a few considerations here, but I’m focusing on the life threatening consideration and working backwards from there.
  • Work-related back injuries
    • This isn’t as much a life-threatening consideration as it is a limb and career-threatening one.  Given the degree of disability that is work-related and the need to continue working at the same level of productivity required to keep your job, it’s a pretty good idea to have incremental changes in symptoms and function assessed.  Ignoring symptoms when they occur can lead to failure to qualify for worker’s compensation, not to mention it places you at risk for worsening injuries and ongoing disability.

Other diseases present with back pain, including kidney stones and infection, pancreatitis and certain ruptured abdominal organs.  I’d like to make special mention of the latter, which may include abdominal aortic aneurysms and ectopic pregnancies, both of which I’ll address in the future.  The take home consideration here is to use these cues to know when to get rapidly evaluated.  Even though people use the Emergency Room for seemingly everything these days, knowing when time is of the essence for true emergencies is a life-saver.
Feel free to ask your SMA expert consultant any questions you may have on this topic.
Order your copy of Dr. Sterling’s new book Behind The Curtain: A Peek at Life from within the ER at, iTunes, Amazon, Barnes and Nobles and wherever books are sold.
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