The back pain that became a pain in the … back!

Mechanism. Never forget mechanism of injury when assessing a patient with any sort of trauma. We tend to get distracted by other people’s assessments, or their version of events, or their assessment of injuries – do NOT fall into that trap. Always start from scratch, when you are the one responsible ultimately. And always, ALWAYS take mechanism of injury into consideration, however minimal the injuries may seem to be.

Quite a while ago now, I had a patient in ED, middle-aged female who had a background of hypertension and had previously had some chronic respiratory illness, and a heart rhythm abnormality called atrial fibrillation, for which she was on warfarin – an anticoagulant. She had come in with the history of traumatic back pain. As the story went, she had been lifting some sort of semi-heavy load outside her house, and had turned around (or intended to turn around) and fallen over backwards on 2 very low steps, in the process also managing to hit her head against a brick wall. She did not lose consciousness, and her husband heard her scream, and came out of the house at once to help her. She was unable to get up on her own, but with help got to her feet and felt fine. Due to her hitting her head, her husband felt they should get a check up, so they came into the ED. Enter yours truly – their saviour in shining armour. Or not.

I assessed the patient, took a detailed history, and fully examined her. I had in the back of my mind right from the outset that she needed a scan of the head due to her head injury while being on warfarin. She denied any neck pain, and had no palpable tenderness of the bony bits in her c-spine, or neck. She also complained of mid to lower back pain, but not in the midline, rather on the right side. I specifically felt all the palpable bony aspects of her vertebral column from top to (literal) bottom, and it did not elicit any pain. There was no bruising (surprising, since she was on an anticoagulant, and had literally landed on her back on the stairs). She had full range of motion of her majors joints, and had walked in to the department to be assessed. For all intents and purposes, her major injury was the head wound, and for that I requested a CT scan of the head. It came back as normal. I found no reason to investigate anything else. Her back pain wasn’t too severe, but I still advised her to take regular analgesia, and to seek medical help if it was worsening, or not improving after a few days, or if she had any other concerns (a typical statement for me when I discharge any patient). I sent her home with some head injury advice, instructing her husband on the red flag signs to look out for, and if any concerns to come back to us. I documented the whole encounter, and went on to see my next patient.

I found out later that the patient had returned 2-3 days later, because her back pain had not improved, rather it had become much worse, and she found it difficult to mobilise out of bed. One of my other colleagues very kindly examined her this time, there was still no bony tenderness in her back, and her pain seemed to be localised to the right side of her lower back, and my colleague agreed that it seemed very much like a soft tissue injury. However, because this was the patient’s second visit to ED with the same complaint – and the situation had worsened to the point that her activities of daily living were being hampered (like getting out of bed!) – he requested an x-ray of her thoracolumbar spine, which revealed to my extreme embarrassment and shock a wedge fracture of one of the vertebral bodies. She was admitted under orthopaedics, and I crawled into a hole and died. No I didn’t.

I read up on traumatic back pain, and I gathered as much information as I could about it. I also gave a presentation to my other colleagues in the department, as a learning point. Here is what I learnt, and I utilise this information everyday: Whenever assessing traumatic back pain, the method that I have been taught and always employed was the one I have described. What is now advised, is to not just palpate the bony prominences of the vertebrae, but to place one hand on the bony prominence of the spine at any level – with the palm resting on the back; then make a fist out of your other hand, and lightly tap the fist onto the back of the hand that is flat on the back – if it elicits any pain anywhere on the back, investigate further (do x-rays) – and assess the whole vertebral column integrity in this fashion.

I have also learnt after discussing this at length with many of my colleagues of varying seniority and specialty, that even though clinically an x-ray may not have been warranted at the first presentation, yet purely based on mechanism if you looked at it, along with her age group (women middle-aged and above are more likely to begin to have osteoporotic fractures with moderate trauma), an x-ray would not have been completely out of the question.

To this day, I am terrified when I see ‘back pain – fall’ as my next patient’s presenting complaint. But I am more, much more cautious now, and I am sharing this experience to highlight how easy it is to miss something even if you are looking for it at the right place and at the right time, and I hope this post will serve to help/guide someone to not make the same mistake I did. Cheerio!

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