Peter Scriven, DO
Resident Physician
Ohio State University
Grove City, Ohio, United States
Christopher Benhatzel, DO
Fellow Physician
Ohio State University
Columbus, Ohio, United States
A 53-year-old female with a medical history of multiple sclerosis presented to clinic for evaluation of an acute L1 compression fracture sustained 6 days prior. On initial presentation to the emergency department, she had no red flag symptoms, achieved modest pain control, and was discharged home. At follow up, she had severe, unrelenting, stabbing midline and right lower back pain radiating to her groin. Movement worsened her pain. Physical exam showed acute distress related to pain with diaphoresis, lumbar midline tenderness to palpation and percussion, and 4/5 muscle strength in the right lower extremity. The acuity of weakness and unrelenting pain was concerning for progression of her compression deformity and potential cord or nerve root compromise. She was sent to the ED. Imaging redemonstrated the compression fracture without retropulsion, nerve root compromise or cord compression, with obstructing hydronephrosis from renal calculi. She underwent ureteral stent placement with improvement of symptoms.
Discussions:
Back pain is one of the most common causes of clinic and emergency room visits and the differential diagnosis is broad. Most cases are musculoskeletal in etiology. However, it is imperative to think about cord compression and intraabdominal origins as a source of pain. The most essential aspect of back pain management is identifying red flags and deciding the proper treatment, avoiding delays in early intervention. Red flags include but is not limited to bowel/bladder incontinence, loss of sensation or weakness in lower extremities, colicky pain, saddle anesthesia, or radiating pain to the groin or abdomen.
Conclusions:
This case aims to demonstrate the importance of recognizing red flag symptoms and keeping a broad differential, avoiding anchoring bias. In the case of back pain, the clinician should use a comprehensive history and physical exam to identify potentially harmful or life-threatening conditions.
