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

Your next step in evaluation and management is…

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Your next step in evaluation and management is…
A) Repeat plain films, and if normal send patient home on oral narcotics/anti-inflammatories.

B) Arrange for outpatient MRI within the next two weeks.

C) Patient is displaying classic drug seeking behavior. You prescribe tylenol and ibuprofen, and recommend outpatient physical therapy and substance abuse counselling.

D) You insist on ordering MRI immediately, even though radiology argues that this is not needed emergently because the ESR/CRP are normal.

Answer is D.
This is a real case. Urgent MRI revealed L3-L4 osteomyelitis; cultures subsequently grew Veillonella (gram negative anaerobe). Patient has a major red flag in his history, which is current IVDU, and although inflammatory markers are normal, this history cannot be ignored. Normal plain films have high false negative rates for osteomyelitis. Waiting a few weeks for outpatient MRI is not advisable, as spinal cord compression or spine instability can develop quickly if infection is present. Back pain needs to be taken seriously in IVDUs regardless of concern about drug-seeking behavior.
2) 68 yo male with h/o CAD and hypertension presents with abrupt onset of upper back pain radiating to the abdomen and hips. BP is 180/90 at presentation, exam otherwise normal except diminished lower extremity pulses bilaterally. CXR and EKG wnl, labs notable only for creatinine 2.0. Helical CT scan reveals descending aortic dissection from the proximal descending thoracic aorta to infrarenal.

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