When back pain may be a medical emergency

Most types of back pain can be successfully managed over a patient’s lifetime through a combination of non-surgical treatments, such as exercise and pain medications, and possibly surgery. However, certain back pain symptoms are a sign of a medical emergency that may become life threatening or result in disability without prompt attention from an experienced physician. Patients who experience any of the following symptoms should seek medical attention as quickly as possible:

• Progressive leg weakness and/or loss of bowel or bladder control

• Unexplained weight loss accompanied by pain and neurological impairment

• Acute, severe stomach pain along with low back pain such that the patient can not stand straight

• Fever with increased pain which does not respond to common fever reducers

Progressive leg weakness and loss of bladder or bowel control

Patients who experience sudden bladder and/or bowel incontinence (dysfunction that causes retention of urine, inability to hold urine in, or loss of rectal control), or feel progressive weakness or numbness in the hips and legs should seek immediate medical attention. These symptoms are indicative of cauda equina syndrome, which is usually caused by a compressed nerve in the lower spine.
Typical symptoms include:

• Severe or progressive weakness, numbness or altered sensation in the lower extremities - the legs and/or feet

• Loss of sensation or altered sensation in the “saddle” area (the area where a body is positioned on a saddle: inner thighs/between the legs, buttocks, back of legs, sacral region)

• Difficulty walking without stumbling because of pain or numbness or weakness in one or both legs

Left untreated, cauda equina syndrome can result in paralysis, or loss of sensation in areas below the lower spine if the nerve is permanently damaged.

Unexplained weight loss, loss of appetite, pain and neurological problems

Adult patients who have weighed the same for months and for no apparent reason lose weight rapidly (e.g. more than 5 pounds a week for a couple of weeks) or lose their appetite for even favorite foods should consult with their doctor. Rapid, unexplained weight loss can indicate a serious medical condition, such as cancer. For example, a tumor that is lodged in or around the spine would typically result in the following symptoms:

• Pain in the neck or back, followed by neurological problems (such as weakness or numbness of the arms or legs or a change in normal bowel or bladder habits)

• Back pain that does not diminish with rest, and pain that may be worse at night - even waking the patient during sleep - than during the day

• Any of the above symptoms along with loss of appetite, unplanned weight loss, nausea, vomiting, or fever, chills or shakes

A CT scan and blood tests will most likely be ordered as preliminary steps to identify the cause of symptoms.

Severe, continuous abdominal and lower back pain

Low back pain from a spine condition generally is localized in the back or extremities affected by nerves aligned with spine segments. Rarely does low back pain migrate to the abdomen. However, abdominal disorders can often extend to the low back and be experienced as acute low back pain.
Acute (meaning quick onset) lower back pain that does not follow an obvious trauma, or movement associated with the onset of pain, can be a symptom of an enlargement of the aorta (large artery) in the abdomen, called an abdominal aortic aneurysm. This condition becomes a serious medical emergency if the blood vessel ruptures or internal bleeding occurs.

The primary symptoms of an abdominal aortic aneurysm are unremitting sharp and crushing pain in the low back and abdomen, so severe that it can prevent someone from being able to stand up straight, leaving them literally doubled over in pain.

Unresponsive fever followed by increased pain

Fever (defined as a sustained temperature of more than 101° in adults) can indicate an infection. In the spine an infection can arise gradually if the immune system has been weakened, or it can occur following surgery. Although relatively rare, spinal infections can give rise to an epidural abscess (a pus-filled cavity in the epidural space) that can press on the nerve structures in the cervical or thoracic spine. This can impair gross motor skills, and result in paraplegia or quadriplegia.

Most infections can be treated successfully with antibiotics if brought to the attention of a physician.

• Post-surgical or wound infections occur in about 1% of patients, and more frequently in diabetics or people in poor health. An infection may develop 1 to 2 weeks after the procedure, even as pain from the surgery is abating. The most common infection is a wound infection, which results in a fever of greater than 101 degrees, increased redness and pain around the incision, and a change in drainage from the wound, such as clear discharge becoming yellow and thick and the wound not closing.

• A vertebral body infection (called vertebral osteomyelitis, or bone infection) spreads to the spine by veins carrying bacteria generated in other parts of the body. This kind of infection could arise after a urologic procedure such as a colonoscopy or a cystoscopy, a diagnostic test using a thin telescope to inspect the bladder, often prescribed when there is blood in the urine or before prostate surgery. Other conditions that make a vertebral body infection more likely are intravenous drug abuse, or long-term use of epidural steroids (e.g. to treat rheumatoid arthritis), because both of these activities increase the chances that bacteria will be introduced to the body.

Fortunately, the vast majority of patients with back pain will not experience any of the above symptoms. However, if these or any other unanticipated symptoms arise, the wisest course of action is to immediately consult with a doctor.

By: Ari Ben-Yishay, MD

June 12, 2007