Emergency Room Treatment for Severe Back Pain: A Provider's Perspective
As a former emergency room (ER) provider, I have had the privilege of caring for countless individuals who arrive at the ER with severe back pain. This article offers insights and hypothetical examples of what you can expect during an ER visit for severe back pain from the perspective of a healthcare provider who specializes in emergency medicine.
What Will They Do in the Emergency Room for Severe Back Pain: The Importance of Immediate Care
When patients present with severe back pain, it is essential to recognize that this symptom can have various causes, some of which require immediate medical attention. Our primary concern in the ER is to ensure your safety and provide timely, effective care.
It is often a misunderstanding that the ER is a first come, first served means of seeking medical attention. It is our priority to ensure medical emergencies are stabilized first and often long waiting room times are due to medical teams attending to life or death situations behind closed doors.
Medical professionals are trained to triage or prioritize patients coming into the emergency room and typically do so in an “A, B, C”- like fashion meaning:
1) Airway: Does the patient have an open airway to breathe?
2) Breathing: Is he/she breathing? Is the patient receiving adequate oxygenation? Is the patient breathing too fast or too slow?
3) Circulation: Does the patient have a life sustaining blood pressure? Is his or her blood circulating appropriately?
What Will They Do in the Emergency Room for Severe Back Pain: Red Flags
One of the first things we consider when evaluating severe back pain is whether any "red flags" are present.
These may include weakness or numbness in the legs, loss of bladder or bowel control, or a history of cancer. These signs can indicate potentially serious underlying issues that demand swift action.
Patient Hypothetical Examples:
A patient arrives at the ER with severe lower back pain and numbness in both legs. After a thorough evaluation, it is discovered that a large herniated disc is compressing the spinal cord of the patient. The urgency of the situation is clear, and the next step is to promptly initiate treatment to prevent any further neurological damage.
Back pain resulting from a fall, motor vehicle accident, or other trauma can be especially concerning. Traumatic injuries may involve fractures or dislocations that necessitate approach. These types of patients not only need pain management, but also orthopedic or neurosurgical consultations.
Coordinating care with specialists is vital to achieving the best possible outcomes in these situations. When a patient arrives with unrelenting and excruciating back pain that doesn't respond to over-the-counter pain relievers, it is a clear indication that further evaluation and intervention are warranted.
Oddly enough, there are two extremes of self-reported pain. Sadly, in cases of drug seeking behavior, the patient may overreact or report false pain. In these instances, the ER team must use thorough assessment as well as diagnostic tools and imagery to ensure a proper diagnosis.
In other cases, sometimes patients downplay the severity of their pain, attributing it to common issues like muscle strains. Severe and persistent pain can significantly impact one's quality of life.
It is essential to communicate your pain's intensity and persistence when seeking help in the ER. In cases of spinal fractures, we collaborate with orthopedic specialists to consider surgical interventions or bracing to stabilize the spine.
Two Patient Hypothetical Presentations: “John and Jill”
On a sunny Saturday afternoon, the emergency room is abuzz with activity. Among the patients, there's “John”, a 25-year-old college football player who's been brought in by his teammates. He is lying on a stretcher, clutching his lower back, and winces with every movement. The athletic trainer who accompanied John to the ER explains that during a game earlier that day, John was tackled hard and landed awkwardly on his back.
Primary Survey: The triage nurse, Lisa, first ensures that John's airway, breathing, and circulation are stable. He's conscious and responding but is in visible distress, with a racing heart rate due to the pain.
Secondary Survey: The medical team conducts a more detailed assessment of John's back pain. He describes it as intense, centralized in his lower back, and he has numbness and tingling in his legs, which are red flag symptoms.
Differential Diagnosis: Weighing the Possibilities
Spinal Cord Injury: Given the mechanism of injury and John's symptoms of numbness and tingling in his legs, there is a concern for a spinal cord injury. This is a red flag condition that requires immediate evaluation.
Fracture: A vertebral fracture is another possibility, especially after a high-impact injury like the tackle. A fracture could be compressing nerves or the spinal cord.
Disc Herniation: Although less likely, a disc herniation could be causing nerve compression and the associated symptoms. It's essential to rule this out.
CT Scan: A computed tomography (CT) scan is ordered to assess the condition of John's spine and confirm or rule out any fractures or dislocations.
MRI: An MRI might be scheduled to evaluate soft tissue structures, such as the spinal cord and intervertebral discs, for any abnormalities.
Immobilization: John's spine is stabilized with a neck collar and backboard to prevent any further movement and potential exacerbation of the injury.
Pain Management: He is administered pain medication intravenously to alleviate his discomfort.
Consultation with a Spine Specialist: Due to the red flag symptoms and the possibility of a spinal cord injury, a spine specialist is urgently called in to assess John's condition and decide on the course of treatment.
Neurosurgical Evaluation: Depending on the CT and MRI results, if a spinal cord injury or severe spinal cord compression is confirmed, a neurosurgeon may need to be involved to discuss potential surgical intervention.
Recovery and Discharge:
The diagnostic tests reveal that John has a severe vertebral fracture with a significant impact on the spinal cord. He undergoes emergency surgery to stabilize the spine and decompress the cord.
Following surgery, he begins a comprehensive rehabilitation program to regain function and mobility. John's case highlights the importance of recognizing red flag symptoms, like numbness and tingling in the extremities, in patients with back pain, especially when a high-impact injury is involved.
Swift and appropriate medical intervention can make a significant difference in the outcome, particularly in cases of potential spinal cord injury.
Hypothetical Patient #2: “Jill”
It is a Friday evening, and the emergency room is buzzing with activity. “Jill”, a 45-year-old woman, arrives at the ER accompanied by her husband. She's gripping her lower back, and her face is contorted in agony. Jill explains that earlier in the day, she had been moving some heavy furniture and suddenly felt a sharp, tearing pain in her lower back.
Primary Survey: The triage nurse, Mark, quickly ensures that Jill's airway, breathing, and circulation are stable. She's able to speak and breathe normally, but her blood pressure is slightly elevated due to the pain.
Secondary Survey: The healthcare team asks Jill to describe the nature of her pain. She reports it as a severe, constant ache in her lower back, which worsened after moving the furniture. The sudden onset of pain is a key clue, which raises suspicions of a muscle tear.
Differential Diagnosis: What are the Possibilities?
Muscle Tear: Given Jill's history of lifting heavy furniture and the acute onset of pain, a muscle tear is the most likely diagnosis. When lifting heavy objects or with improper technique, it's common for the muscles in the lower back to overexert and potentially tear.
Ligament Sprain: Another possibility is a ligament sprain. The force exerted during lifting could have strained or partially torn a ligament in her lower back, causing pain.
Discogenic Pain: Although less likely in this scenario, it's essential to consider discogenic pain. A herniated disc could be pressing on a nerve, leading to pain in the lower back. However, Jill's pain description is more consistent with a muscle injury.
In cases of muscle tears, imaging studies are not always necessary for diagnosis, but they can help confirm the extent of the injury and rule out other potential causes.
X-ray: An X-ray might be performed to check for any fractures or bone-related issues, but it's unlikely to show a muscle tear.
Pain Management: Jill is in considerable pain, and immediate pain relief is a priority. She's given pain medications through an IV to ease her discomfort.
Rest and Ice: Jill is advised to rest her back and apply ice to the area to reduce swelling and pain.
Physical Examination: A physical examination is conducted to assess the severity of the muscle tear. The doctor palpates the area and asks Jill to perform certain movements to gauge her range of motion and level of discomfort.
Orthopedic Consult: If the physical examination suggests a significant muscle tear, an orthopedic specialist may be consulted to evaluate the extent of the injury.
Muscle Relaxants: Depending on the assessment, Jill might be prescribed muscle relaxants to ease muscle spasms associated with the injury.
In some situations, we may recommend physical therapy or refer you to a specialist to facilitate long-term recovery and pain management.
Provider's Perspective: Physical therapists play a crucial role in helping patients regain function and prevent future back pain. Their expertise in prescribing exercises and techniques for pain relief is instrumental in the recovery process.
Rest and Observation
In specific cases, we advise patients to rest and remain under observation in the ER. This is particularly relevant when there are concerns about nerve involvement or severe pain that requires close monitoring.
Provider's Perspective: Our vigilance during the observation period is aimed at detecting any changes in neurological function or pain intensity. This allows us to make real-time adjustments to the treatment plan and ensure patient safety.
Referral and Follow-Up
Following your ER visit, we may refer you to a specialist or instruct you to follow up with your primary care provider. Continuity of care is essential for managing complex back pain cases and ensuring ongoing improvement.
Provider's Perspective: Collaborating with specialists and primary care providers is vital for providing comprehensive care. We rely on their expertise to offer specialized interventions and long-term management strategies tailored to each patient's needs.
Recovery and Discharge:
Over the following days, Jill's pain gradually subsides with rest and medication. She's instructed on proper body mechanics and advised to avoid strenuous activities. A physical therapist provides guidance on exercises to strengthen her back muscles and prevent future injuries.
Jill is discharged with a prescription for pain relief and muscle relaxants, as well as a referral for outpatient physical therapy to aid her in her recovery. She's also educated on proper lifting techniques to prevent a recurrence of her injury.
Jill's case highlights the importance of recognizing the potential for muscle tears in patients who present with acute, severe back pain, especially if there's a history of heavy lifting or sudden, strenuous activity. A prompt and accurate diagnosis allows for timely intervention and an effective treatment plan.
What Will They Do in the Emergency Room for Severe Back Pain: Conclusion
Severe back pain can be a challenging experience, both for patients and healthcare providers. When you seek prompt medical attention in the emergency room, you enable us to provide the relief and care you need.
Remember that not all back pain requires an ER visit, but if you experience red flags, trauma-related pain, or severe and persistent symptoms, don't hesitate to seek immediate medical help.
It is important to note that the emergency room is not a place to seek regular treatment for prolonged chronic back pain. Chronic back pain is best treated in an outpatient setting under the continuity of primary care and collaborative pain management, physical therapy, sports medicine, chiropractic, and orthopedic specialists.
The ER team is dedicated to evaluating, diagnosing, and treating a wide range of conditions, ensuring that you receive the appropriate care for your back pain. By taking swift action and following up with the necessary healthcare providers, you can embark on a path toward a healthier and pain-free back.