Attending Version: Back Pain Emergencies Module; created by Dr. Wendy Gerstein

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III. Physical Exam:

Visual – pale/ashen?

Inspect back looking for previous surgeries, deformities, swelling/point tenderness/redness/skin lesions (zoster?).

Gait – dragging leg? (focal deficit), Leaning over? (spinal stenosis), pacing room? (kidney stone)

CV: Aortic regurgitation murmur? (high dissecting aortic aneurysm)

Abdominal exam – Pulsatile mass/bruit? (AAA)

GU/Rectal – evaluate sphincter tone, check PVR.

Extremity exam – sensory and muscle strength, pulses.

Babinski/reflexes (looking for upper motor neuron signs consistent with spinal cord compression).
Red Flags” on physical exam/labs:
A. Loss of sphincter tone and/or perianal numbness/urinary retention

B. + Babinski and/or hyperreflexia

C. New or progressive muscle weakness/sensory deficits

D. Elevated wbc or esr

E. Fever

F. Hypotension

G. Unequal pulses/bp readings on extremities

H. Extreme Hypertension

I. Pulsatile abdominal mass

J. Hypercalcemia

IV. Imaging
A. Plain films – useful if evaluating for fracture, but high false negative rate (40%); also part of work up for multiple myeloma.

B. MRI – test of choice for radiculopathy, spinal cord abscess, osteomyelitis, spinal tumors, spinal stenosis, and vascular lesions.

C. CT scan – better for bone imaging – if h/o spinal trauma and/or vertebral fractures, or if suspecting AAA rupture/dissecting aortic aneurysm.

D. Bone scan – for evaluating for osteomyelitis, occult fracture, bony neoplasms (except multiple myeloma).

E. TEE – for dissecting aortic aneurysm

F. Ultrasound – evaluating AAA

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