A 49-year-old man presents to the emergency department with an acute onset of back pain. He was carrying some heavy groceries and felt something pull in his lower back. He took some naproxen, which he uses as needed for an old high school football injury, but is still in pain. You do not find any red flags on the history and physical examination. He is feeling better after a dose of morphine, but he still has difficulty bending and walking. It’s time to consider what medications to discharge him home with.
There are about 2.7 million visits to the emergency department annually for low back pain. While the vast majority of visits are due to benign conditions, this diagnosis can be frustrating for patients and physicians.
One thing physicians have to consider is not missing the uncommon but dangerous conditions like spinal epidural abscess, osteomyelitis, cauda equina syndrome, and pathological fractures. Multiple red flag lists have been published to help physicians identify patients at risk for some of these serious conditions (eg, TUNA FISH, see Table 1). While no list is complete, they can be helpful.