Certification Exam

Red flags of back pain should immediately alert the emergency team to a serious cause of a patient’s back pain. Back pain that is unremitting, associated with fevers or chills, in an immunocompromised patient (such as a patient with HIV or diabetes), or associated with an elevation in inflammatory markers (such as an elevated ESR or CRP) all raise concern for infection such as an epidural abscess, vertebral osteomyelitis, or discitis. Concerning findings for back pain that may require a surgical intervention such as cauda equina syndrome include midline back pain (suggesting a fracture), lower extremity weakness or paresthesias, loss of rectal tone, and urinary or fecal retention or incontinence. An elevated postvoid residual volume (with 200 mL as a common cutoff) is highly concerning for cauda equina syndrome and, in the appropriate clinical setting, warrants an MRI and spine surgery consultation.

Pain that is exacerbated by twisting (A), pain that is worse after a long workday (B), and paraspinal tenderness on exam (C), in addition to pain worse with stretching, are all suggestive of a muscle strain, which requires only analgesia, hot or cold packs, and recommendation to engage in activity as tolerated and outpatient physical therapy.