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Author: Michael Canty

Acute spinal pain represents a significant diagnostic challenge. Possible causes can range from benign musculoskeletal pain requiring little treatment, to a first presentation of malignant disease in a young person. While serious causes of spinal pain are uncommon, recognizing them early and intervening appropriately requires careful assessment of all such patients.

Lumbar spine, or low back pain, is the most common form of this presentation, and possibly the least likely to have a serious underlying cause. Low back pain will affect the majority of the population at some point during their lives, and is often short-lived. Cervical and thoracic spine pain are less common. They are more likely to have a sinister cause, although the majority of these patients again have a benign diagnosis.

Priorities ⬆ ⬇

  1. Clinical assessment

    Look for ‘red flag’ features indicative of serious pathology (Table 29.1). Examine the spine and perform a full neurological examination, including assessment of perineal and perianal sensation, and anal tone (Box 29.1).

    • Young patients rarely experience significant back pain and are unlikely to have established degenerative disease. Older patients will have conditions such as osteoporosis or primary cancers that predispose to serious spinal problems.
    • Spinal pain following trauma may represent an unstable fracture, or collapse in the presence of osteoporosis.
    • A primary cancer and nocturnal spinal pain are predictors of secondary spinal malignancy.
    • Thoracic spine pain is an unusual symptom and must always be taken seriously. In young patients it is particularly concerning and may be due to a sinister cause.
    • Systemic features such as fever, sepsis, or weight loss suggest a generalized illness such as cancer or infection, which may have begun to involve the spine.
    • Instability pain indicates a potential loss of spinal integrity, such as collapse, with resultant deformity secondary to malignancy, infection or benign fracture. It is characterized by pain present on mobilizing but usually absent at rest.
    • Perineal/perianal or ‘saddle’ numbness, is a hallmark of cauda equina syndrome and must never be ignored.
    • Bladder symptoms (especially inability to pass urine, or incontinence), and more rarely, bowel symptoms, may be due to cauda equina or spinal cord lesions.
    • Progressive limb neurology suggests significant nerve or cord compression and urgent investigation is required.

  2. If malignant spinal cord or cauda equina compression is suspected, arrange emergency MRI imaging of the entire spine.

    If MRI imaging is unavailable, discuss with Neurosurgery or Oncology whether referral for imaging elsewhere is indicated. Consider CT scanning of the spine.

  3. If cauda equina syndrome is present, even if not thought to be malignant, arrange emergency MRI imaging of the lumbosacral spine.

    If MRI imaging is unavailable, discuss with the relevant spinal regional centre whether transfer for imaging is indicated.

  4. If a significant traumatic injury is suspected, or a spinal deformity due to any cause is present, imaging with either CT or MRI will be required.
    • Discuss choice of imaging with Radiology.
    • Plain X-rays may confirm the diagnosis and expedite cross-sectional imaging, but they are not definitive.
  5. If spinal infection is suspected, obtain urgent bloods for full blood count, C-reactive protein, creatinine and electrolytes and bone profile. Take blood cultures.
    • Look carefully for a primary source.
    • Arrange urgent MRI imaging of the relevant area of the spine. Consider imaging the entire spine.
  6. If nerve or cord compression is suspected, but not thought to be acute or malignant (e.g. lumbar radiculopathy without features of cauda equina syndrome; degenerative cervical myelopathy), routine inpatient MRI is usually appropriate.

Further Management ⬆ ⬇

  • Patients with a confirmed diagnosis of malignant spinal cord or cauda equina compression should be referred immediately to Neurosurgery and/or Oncology.
  • Cauda equina compressions due to acute disc prolapse should also be referred immediately to Neurosurgery or the regional spinal service.
  • Traumatic spinal injuries and spinal infections should also be discussed with Neurosurgery or the regional spinal service, although many of these patients will be managed non-surgically and do not require transfer.
  • Patients with lumbar radiculopathy are usually managed on an outpatient basis by spinal surgeons. Discussion with the relevant specialty should take place if any uncertainty exists over the urgency of referral. Cervical myelopathy is also usually managed initially in outpatients, albeit on an expedited basis; it is prudent to discuss with the on-call specialty.
  • Osteoporotic collapse is managed by multiple modalities and specialties, but almost never by surgery. Vertebroplasty is advocated by some and may be appropriate in selected cases; it is usually provided by interventional radiologists.
  • Patients without a significant diagnosis following investigation usually have musculoskeletal pain and are managed by adequate analgesia, mobilization and physiotherapy. Some patients will have an underlying rheumatological cause such as an inflammatory arthropathy and should be discussed with Rheumatology for further advice and management.

Further Reading ⬆

Berbari EF, Kanj SS, Kowalski TJ, et al. (2015) Infectious Diseases Society of America: clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adults. Clinical Infectious Diseases 61, e26–46. http://cid.oxfordjournals.org/content/early/2015/07/22/cid.civ482.full.

Della-Giustina D (2015) Evaluation and treatment of acute back pain in the emergency department. Emerg Med Clin North Am 33, 311–326.