Chapter 7

Low back pain

• Triage
• History
• Physical exam
• Differential diagnosis
• Diagnostic tests
• Hospital/office course
• Pitfalls
• Errors and interesting cases

Low back pain is a common complaint during visits to both the primary care
office and the emergency department. A significant percentage of these patients
have low back pain that may be work-related with its inherent legal
implications. In fact, low back pain is the most common cause of disability among
adults less than 45 years of age.1 Most cases of low back pain represent simple
mechanical pain and require only supportive treatment and lifting instructions.
However, the physician must not take every low back pain for granted because
there are also some potential serious causes. Our friend, Jeff Abraham, MD, who
is the emergency director at Baypines Veterans Administration hospital, states
it best: ‘If you have never had a bad outcome from a low back pain, you have
not treated enough low back pains.’

Triage
Any patient with low back pain and ‘red flags’ should be seen emergently. ‘Red
flags’ for low back pain emergencies include fever (epidural abscess), new
neurologic symptoms (spinal cord compression), bowel or bladder problems
(cauda equina syndrome), abdominal pain (aortic aneurysm or dissection), and
other abnormal vital signs (hypotension with ectopic pregnancy). Other
possible warning signs or symptoms are hematuria (renal infarct), weight loss
(malignancy with bone metastases), trauma history, and vaginal bleeding
(ectopic pregnancy). Patients without any red flags but appearing in moderate
distress should be seen urgently for evaluation and pain control. Patients who
appear comfortable and have no ‘red flags’ can be triaged in the usual order of
urgency. The exceptions to this rule are the older patient (greater than 65 years
of age), the patient with vascular disease, and the possible pregnant patient who
may have more serious etiologies.
120 Learning from medical errors: clinical problems

History
A detailed history of the patient’s low back pain should be obtained in the usual
fashion as with any other pain complaint. In addition, inquire about any previous
history of low back pain and whether imaging has been performed and if there
are new symptoms. Helpful details of the patient’s back pain include trauma
history, radicular symptoms, perianal or saddle numbness/paresthesia, loss of
bowel or bladder function, or new neurologic deficits.2 Assess if the patient has
a history of cancer (spinal cord compression), blood thinner use (epidural
hematoma), peripheral vascular disease (abdominal aortic aneurysm), and
intravenous drug use or tuberculosis history (epidural abscess).
Ascertain whether there are associated symptoms with the back pain such as
abdominal pain, dysuria, hematuria, or fever. Is there a prior history of
genitourinary diseases such as kidney stones, urinary tract infections, or pyelone-
phritis? These diseases have inclinations to cause low back pain. For the female
patient, is there a history of ovarian cyst or can the patient have an ectopic
pregnancy? An occupational history is frequently necessary if there was a
precipitating injury at work. Knowledge of the patient’s occupation and duties
is mandatory in order to devise an appropriate treatment plan. Additionally,
documentation needs to be thorough because of the increased predilection for
these injuries to result in legal action.

Physical exam
As with any other complaint, we prefer to have recorded all five of the vital signs
in the patient with low back pain. However, since this complaint is so
common, vital signs are frequently not complete in these patients. We suggest
that a minimum of temperature and blood pressure recordings be made. These
two vital signs may direct us to more serious etiologies of low back pain such
as infection and vascular disease.
An abdominal exam should be performed and documented for all patients
with low back pain who have hypertension or risk factors for peripheral
vascular disease. Please see Case 7.1. Note whether there is a pulsatile mass in
the abdomen or whether there are unequal pulses in the groin. Although these
findings do not have great sensitivity in detecting abdominal aortic aneurysm
or aortic dissection, they do demonstrate that you considered these diagnoses.
Furthermore, the abdominal exam represents no additional cost to the patient
and poses no medical risks and therefore its exclusion would be inexcusable to
the courts.
A thorough neurologic exam is essential in patients with low back pain. This
includes sensation and motor testing as well as testing of reflexes. The patient’s
gait or inability to walk should also be recorded. In suspected cases of cauda
equina syndrome, a rectal exam for rectal sphincter tone should be performed.
In fact, Grudem and Schwartz recommend in Principles and Practice of Emergency
Medicine: ‘for all patients with acute low-back pain, a rectal examination for
sphincter tone should be performed on all patients with objective neurologic
abnormalities.’3
The skin of the lower back should be palpated for localized tenderness,
erythema, or swelling. Consider pelvic examination (ovarian cyst) in females or
 Low back pain 121

rectal examination (prostatitis) in males if the etiology is still in question.

Examinations of other organ systems are dictated by the clinical history.

Differential diagnosis
The majority of low back pains arise from the musculoskeletal system (e.g. strain),
the neurologic system (e.g. herniated disc), or the genitourinary system (e.g.
kidney stone, pyelonephritis). These processes usually do not represent true
emergencies. However, there are rare occasions where emergencies can arise
from these conditions. Cauda equina syndrome, kidney stones with pyelone-
phritis, and pyelonephritis with refractory vomiting are examples.
As we discussed above, some causes of low back pain can lead to death or
permanent disability if not timely detected. Do not develop the habit of taking
low back pain for granted. Every patient over 50 years of age should have the
diagnosis of abdominal aortic aneurysm considered. Patients with recent back
surgery or procedure (e.g. lumbar puncture) or intravenous drug use could have
an epidural abscess. In addition, cocaine use may lead to renal infarction and
low back pain. Patients with trauma or those on Coumadin may have epidural
hematomas.
Other causes of low back pain may originate from the genitourinary system
or the gastrointestinal system. Gastrointestinal causes of low back pain are rare
and are discussed in the ‘Pitfalls’ section below. Genitourinary causes include:
ovarian cyst or torsion, ectopic pregnancy, uterine fibroids, testicular torsion,
and prostatitis.

Diagnostic tests
Most patients presenting with low back pain will not need any testing. This is
particularly true if there is no history of significant trauma and there are no red
flags (see the ‘Pitfalls’ section below) present. Most will give you a history of
some heavy lifting or some overexertion and will need to be treated
symptomatically for a muscle strain. Another common group will have a history
of herniated nucleus pulposus, degenerative disk disease, or spinal stenosis,
and have had extensive radiology imaging in the past. As long as there are no
new neurologic symptoms, repeat testing with magnetic resonance imaging is
usually not warranted.
Patients with trauma to the lower back will usually require a cross table lateral
X-ray of the lumbar spine while still under spinal immobilization. Subsequently,
the remaining views may be obtained. If there is either a fracture seen or a
fracture not seen in the setting of a high clinical suspicion of a fracture, then a
noncontrast CT scan of the lumbar spine may be obtained. It is often difficult to
assess the amount of retropulsion and involvement of the posterior column (i.e.
the spinal cord) in the setting of a compression fracture; therefore, a CT scan is
helpful to elicit further information. MRI scanning is useful for patients with
new neurologic findings and definitely required for those with new bowel or
bladder compression and saddle anesthesia.
A special mention has to be made concerning abdominal aortic aneurysm and
low back pain. The occurrence is not as rare as people believe. In fact, a friend
of ours once told us that he had worked at a facility where every emergency
122 Learning from medical errors: clinical problems

physician there had sent a patient with low back pain home who was later
discovered to have an aneurysm. Unfortunately, only one of those was caught
before the aneurysm had ruptured. We have seen two deaths from aortic
aneurysms in patients with low back pain in the past five years. This is evidence
that, like myocardial infarctions, you will miss a diagnosis eventually, if you see
enough cases. There are simply not enough financial or technological resources
to get a CT scan or MRI for every patient with low back pain.
We offer the following advice when treating all patients over 50 years of age
with unexplained low back pain. Ask them if they have had a recent CT scan of
the abdomen or MRI of the back within the previous year. If they did and there
was no mention of an abdominal aneurysm in the report, then it is unlikely that
an aneurysm is causing their low back pain. Document all of this in your chart.
If they have not had any recent imaging, then consider getting an abdominal CT
or a lumbar MRI to exclude this. Heavily consider these tests for patients over
50 years of age with concomitant risk factors for peripheral vascular disease.
Remember that this advice does not apply to aortic dissection (see Case 7.1).
Please also see Case 7.6 for our own case of misdiagnosing low back pain.
For patients with low back pain that is unlikely to be musculoskeletal or for
those with urinary symptoms, a urinalysis is usually a good test of choice. It is
helpful for detecting urinary tract infections, hematuria, or pregnancy. A
positive test may eliminate the need for further testing. Females with vaginal
bleeding or spotting should have a urinalysis collected by catheterization to
prevent false positives.
Blood work is helpful for a selective group of patients. A coagulation panel
is useful for patients who are taking Coumadin or heparin as excessive
anticoagulation may lead to epidural or renal hematomas. A reticulocyte count
is pertinent for patients with low back pain and sickle cell disease. Finally, a
complete blood cell count may assist in the diagnosis of infections (e.g. pyelone-
phritis, epidural abscess) or hemorrhagic ovarian cysts.
Other testing for low back pain should be ordered as dictated by the clinical
symptoms. A pelvic ultrasound should be ordered if ectopic pregnancy or
ovarian pathology is suspected. CT urogram is rapidly becoming the test of choice
for the detection of ureterolithiasis. It is much more sensitive and gives much
more information on the degree of renal obstruction when compared to an
intravenous pyelogram. Finally, patients with suspected testicular torsion require
a scrotal ultrasound with Doppler color flow.

Hospital/office course
As we mentioned above, most patients will present with musculoskeletal or
neurologic back pain. Although these conditions are usually stable and not true
medical emergencies, pain management can sometimes become problematic.
During our careers, we have had to admit more patients for refractory low back
pain than any other type of pain complaint (with the possible exception of sickle
cell disease patients). In the same manner, we have seen more drug seekers present
with the complaint of low back pain than with any other complaints. Therefore
the choice of analgesic treatment used and the careful documentation of this are
extremely important in these patients.
For patients with acute emergencies, the rapidity of diagnosis and treatment
 Low back pain 123

is essential to prevent an adverse outcome. Timely conversations with consult-

ants are sometimes needed before the results of diagnostic tests are available.
Similarly, obtaining and reviewing old records may save crucial time spent
waiting for current tests (e.g. prior history of abdominal aortic aneurysm,
history of large ovarian cysts).
A significant percentage of patients who present with low back pain will leave
your office or your emergency department with a diagnosis of uncertain etiology.
These patients require explicit and strict instructions to return if the pain
worsens, new neurologic symptoms develop (including bowel or bladder
problems), fever develops, or other symptoms such as light-headedness,
abdominal pain, or vaginal bleeding occur. Have the patient return or follow up
with their primary physician in a few days if there is no improvement for further
testing (e.g. CT scan, ultrasound, etc.).

Pitfalls
Low back pain accompanied by red flags represents serious etiologies and
warrants more extensive evaluation to prove otherwise. These red flags include:
fever, abdominal pain, weight loss, bowel or bladder problems, weight loss,
urinary symptoms, and new neurologic symptoms in the lower extremities. They
may also include historical clues such as intravenous drug use, recent back
surgeries, and history of cancer, tuberculosis, or sickle cell disease (spinal
involvement). Please see Case 7.2 below.
In the preceding paragraph, we mentioned new neurologic symptoms as a red
flag that requires further evaluation. This evaluation usually means MRI of the
spine since the majority of cases will be diseases of the disks and spinal canal.
MRI is problematic for most hospitals and offices when it is unavailable.
Furthermore, many centers that have outpatient MRI are not open 24 hours a
day. Therefore, a good percentage of the patients who have new neurologic
symptoms will not receive an emergent MRI. The most important determination
for the treating physician is whether there are symptoms of cauda equina
syndrome (please see Case 7.7 below). If symptoms are present, then emergent
treatment (MRI and/or neurosurgical consult) is warranted. If not, then an MRI
done as expediently as possible is a reasonable alternative. This is usually not
that difficult because of the growing popularity of outpatient MRI centers
(including open MRI) that are competing for business.
Disk space infection (diskitis) is frequently not considered in the differential
and, subsequently, the diagnosis will be delayed. This delay may result in grave
consequences and serious complications. 4 This infection can arise by the
hematogenous route (e.g. intravenous drug users) or by direct inoculation (e.g.
post-surgical patients).5 ‘It is characterized clinically by severe back pain and on
radiographs by disk space narrowing and involvement of the adjacent vertebral
end plates. A single vertebral space is usually involved.’5 Some cases may be
associated with a preceding viral illness. However, Wesolowski and Wang point
out in The Spine that ‘radiographic and CT findings in disk space infection may
be partially obscured by post-surgical changes or severe degenerative changes.’6
Therefore, they recommend MRI as the best diagnostic test for this disease. The
difficulty in making this diagnosis is seen in Case 7.3 below.
Although extremely rare, low back pain may sometimes be the clinical
124 Learning from medical errors: clinical problems

manifestation of abdominal pathology. Remember that some abdominal

organs are retroperitoneal and, therefore, may cause low back pain. These
disease processes may be accompanied by abdominal pain but they may some-
times be occult and not present with any abdominal pain. Please see Case 7.4
below.
In evaluating traumatic injuries to the lower back, remember to review all
components of the lumbar vertebrae carefully. A commonly missed fracture is
one of the transverse process. We believe that there is a twofold reason for this
error. The first is that the physician is focused on the central component of the
vertebrae (e.g. spinous process, facets, vertebral body) and often does not notice
the peripheral placement of the transverse processes. The second reason is that
these fractures are rare and usually require great traumatic force. Therefore, some
physicians may have never seen such a fracture while others have lost their
guard to search for them. Please see Case 7.5 below.
We used to believe that there must be a significant mechanism of trauma to
create back pain of neurogenic origin. We also believed that these injuries tend
to occur in older individuals with underlying degenerative disk disease. From
clinical experience, however, we have discovered that this is a misconception
and that neurogenic back pain can result from relatively minor trauma. Please
see Case 7.8 below.
Always consider whether a patient with low back pain is on any
anticoagulants, specifically Coumadin. If they have evidence of bleeding or easy
bruising, check their blood for a coagulopathy and consider the presence of an
epidural hematoma. In the same logic that we scan every patient with a head
injury who is taking anticoagulants, we feel strongly about scanning every spine
in patients on anticoagulants with traumatic low back pain. A missed diagnosis
can result in severe and permanent injury to the patient and a huge settlement
against the physician. Please see Case 7.9 below.

Errors and interesting cases

Case 7.1 Put a hand on the belly

• An elderly man with high blood pressure presented to the emergency
department with two weeks of low back pain that started after he had
bent over to pick up a heavy object. A colleague of ours examined the
patient’s back and performed an X-ray of the lumbar spine. He was noted
to be hypertensive and the X-ray was negative. The patient was discharged
and treated for lumbar strain with pain medicines. He died a few days
later from a ruptured abdominal aortic aneurysm. The physician was
found at fault for not detecting the aneurysm and, more specifically, not
performing an abdominal exam.
• As we discussed previously, it is probably not feasible to perform an
ultrasound or CT scan in every patient with low back pain. The
prevalence of abdominal aortic aneurysm is not high enough to warrant
this. However, it must be considered in all patients with risk factors

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(discussed previously). Simple and inexpensive exams and procedures

should be performed. An abdominal and vascular exam should always
be documented in these patients. Consider an abdominal or lumbosacral
X-ray to look for an aneurysm. If the physician remains in doubt, then
testing for abdominal aortic aneurysm (AAA) should be instigated.

Case 7.2 Red flags of back pain

• A young man presented to the emergency department for low back pain
without trauma on two occasions. He had negative X-rays and was treated
for lumbar strain on both occasions. A temperature of 101ºF was recorded
on the second visit. The patient then returned to the ED two days later
with complete paralysis of his lower extremities from an epidural
abscess. The etiology was from intravenous drug use. This was not
suspected on the first two visits.
• Fever is one of the red flags of low back pain. In the patient with low back
pain and fever, it is prudent to ask about illicit drug use, recent back
surgery, or history of tuberculosis (Pott’s disease). The physician
should also note if there is any erythema or warmth over the involved
area.

Case 7.3 Difficult diagnosis to make

• A 30-year-old restrained male driver came to the outpatient clinic with
low back pain after he had been rear-ended from a stop position. He
complained of severe pain in his lower back that did not radiate to his
legs and was not associated with any neurologic deficits. He also had a
low-grade temperature of 99ºF and cold symptoms for the past week.
The treating physician ordered a lumbosacral series of X-rays and read
them as ‘no acute fracture or subluxation.’ He did not comment on the
size of the disk spaces. The patient was discharged on anti-inflammatories
and muscle relaxants. The patient did not receive any improvement in
his back pain during the next three weeks. He was then sent to a
neurologist who ordered an MRI of his lumbar spine, which confirmed
the diagnosis of diskitis. In retrospect, a narrowing of the disk space was
evident in the patient’s initial X-rays.
• Diskitis is rare and the diagnosis is difficult to make. The findings on
X-rays may be extremely subtle. Be suspicious of it in patients with
elevated temperatures, recent upper respiratory infections, and localized
tenderness over the disks. The presence of any of these factors should
alert the physician to look carefully for disk space narrowing on the
X-ray.
126 Learning from medical errors: clinical problems

Case 7.4 More than pain in the back

• We had an unfortunate case in our first year of practice. An 80-year-old
female came to our ED complaining of low back pain and diarrhea. She
denied any trauma to her back or any heavy lifting. She also had no
urinary symptoms and had no abdominal pain. Her family physician
was currently treating her for Clostridium difficile colitis with metronida-
zole. The patient believed that the colitis was the cause of her diarrhea.
She commented, however, that the diarrhea was improving on the
metronidazole. She denied any fevers but had a temperature of 99.5ºF.
• The rest of her vital signs were unremarkable as well as her physical
examination. This included an abdominal exam, which revealed no ten-
derness, and a rectal exam that was negative for blood. An X-ray of the
lumbar spine and a urinalysis were both normal. A white blood cell count,
however, was elevated at 16,000 cells/microliter. There was also the
presence of a left shift with a 20% bandemia. Our impression was that
the abnormal blood work was a result of the C difficile infection.
• Since the patient stated that the diarrhea was better, we discharged her
and instructed her to continue the metronidazole as prescribed. Two days
later, she returned to the ED with diffuse abdominal pain and was seen
by another physician. He noted a surgical abdomen on physical
examination and immediately called the surgeon to evaluate the patient.
She was taken to the operating room where a segment of her colon was
removed as a result of ischemic bowel. The segment happened to lay in
the retroperitoneal and was the cause of the patient’s low back pain.
• Although the complaint of low back pain usually does not elicit
attention towards an abdominal process, caution should be taken with
diabetics and elderly patients. These groups may have atypical
presentations and the threshold for ordering imaging studies should be
lowered.

Case 7.5 Look both ways before passing

• Edwards presents a case, in The M & M Files, where a traumatic injury
to the lower back was misdiagnosed.7 After slipping and falling down
a flight of stairs, a 28-year-old man went to the ED with low back pain.
He had no radicular symptoms. The ED physician noted localized
tenderness in the mid-lumbar area. The physician then medicated the
patient with pain medicine and ordered a lumbar spine X-ray to look for
a compression fracture.
• When the films were completed, the physician examined them
scrupulously for a compression fracture at the thoracolumbar junction.
After failing to see one, he discharged the patient with pain medicine
and bed rest for a few days. The radiologist looked at the X-rays two days
later and saw that there were transverse process fractures of L2 and L3.
He relayed this finding to the ED physician on duty (not the same one
that saw the patient). The patient was instructed to return for further
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evaluation. His pain had not improved and a urinalysis detected micro-
scopic hematuria. A CT scan was performed to check the integrity of the
kidneys and was found to be normal. The patient was admitted for pain
management. He filed a complaint against the treating ED physician for
missing the fractures.
• As we mentioned above, fractures of the transverse processes are rare
and require a significant force of impact. They also extend to the flank
and therefore, can be associated with injuries to the kidneys. Consequently,
evaluation of patients with these types of fractures should include
consideration for renal or other intra-abdominal organ injuries.

Case 7.6 It pays to be lucky

• This is our own story of abdominal aortic aneurysm as the cause of low
back pain. Sometimes it pays more to be lucky than to be good. This
adage was true when we saw a 55-year-old man with low back pain. He
did not have any apparent risk factors for peripheral vascular disease
and had done some heavy lifting recently. He felt that he had pulled his
back. We obtained an X-ray of the lumbar spine and did not see any
abnormalities with the spine. Subsequently, we discharged the patient
with symptomatic treatment for a lumbar strain.
• Two days later, the radiologist reviewed the X-ray and noticed that there
was abnormal dilatation of his aortic calcifications. He read this as a
probable abdominal aortic aneurysm. We called the patient and had him
come in for a CT scan, which confirmed a 5.3 cm abdominal aortic
aneurysm. He was referred to a vascular surgeon and had elective repair
of his aneurysm in time to prevent a serious complication.
• The AAA may have been an incidental finding and not related to the
patient’s low back pain. However, it was beneficial for us that a radiolo-
gist read this X-ray. Aortic aneurysms are frequently not seen on X-rays
and most physicians (excluding radiologists) rarely look for them. As a
lesson for us, we now try to include a search for them on every lumbar
spinal film.

Case 7.7 Symptoms that cannot be ignored

• Edwards presents another case, in The M & M Files, where a patient with
progressive neurologic symptoms was ignored on multiple visits and
subsequently developed a cauda equina syndrome.8 A 41-year-old man
with no history of back problems went to see his family physician for low
back pain that radiated down his right leg occasionally. He did heavy
lifting with his job but denied any other trauma. The physician gave him
pain medicine and a muscle relaxant and instructed him to undergo two
days of bed rest.
• The patient returned 10 days later and stated that he could now hardly
get out of bed. The physician ordered X-rays of the lumbosacral spine,
which were negative. He then discharged the patient with more muscle
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128 Learning from medical errors: clinical problems

relaxants and pain medicines. The pain became worse that night, prompt-
ing his first visit to the emergency department. Physical exam revealed
normal leg strength but also revealed decreased pinprick sensation in
the right lateral thigh. His back went into spasms with every attempt to
lift his legs. It was documented in the chart that the patient did not have
any bowel or bladder dysfunction and his sphincter tone was normal.
He was given stronger pain medicine and instructed to see his primary
doctor.
• Two days later, when the patient saw his primary physician, his leg pain
was so severe that he required a cane to ambulate. In the waiting room,
he became pale and had a bout of near syncope. An ambulance was called
to take the patient to the emergency department. On this evaluation,
chart documentation showed that the patient denied any bowel or
bladder problems but complained of numbness in his right buttocks that
extended to the groin area. The patient was given a shot of pain medicine
and discharged after some relief.
• Later that night, the pain became even worse and was now accompanied
by the onset of urinary incontinence. A third ED physician evaluated the
patient this time and noted that the patient had distention over his
bladder and a positive straight leg raise on the right. No further evidence
of a neurologic exam or a rectal exam was found in the chart. The
physician ordered catheterization drainage of the bladder and then
discharged the patient with the diagnosis of ‘urinary retention
secondary to cyclobenzaprine.’ He was instructed to follow up with his
family physician.
• On follow-up with his physician, an MRI was ordered, which showed
a large central disc herniation at the L5-S1 level. He was admitted by the
neurosurgeon for cauda equina syndrome and taken to surgery for
removal of the extruded disc segment and decompression of the neural
canal. As a complication of the delay, the patient developed neurogenic
bladder and sexual dysfunction and filed a lawsuit against the hospital
physicians.
• On each of the three emergency department visits, red flags were missed
or ignored by the ED physicians. Numerous errors were committed
including an incomplete evaluation of new neurologic symptoms, ignor-
ing worsening pain, failure to perform a neurologic exam (including one
for rectal tone), and incorrectly attributing autonomic dysfunction to a
medicine. The primary physician could also be held accountable for the
same errors. However, because the primary physician was the one who
ordered the MRI and because he is less likely to see a cauda equina
syndrome in his practice, the public’s perception (and the jury’s) is that
he is less accountable for the misdiagnosis.
• As we discussed above, diseases of the lumbar/sacral spine are frequently
not correctly diagnosed on the initial visit. This is largely due to the
difficulty of obtaining emergent MRI scans. However, this patient
certainly had reasons to raise the physician’s suspicion that a neurologic

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process was ongoing and necessitated more prompt imaging of his back.
Ignoring the worsening of his symptoms and masking them with pain
medicines led to the delay in diagnosis.

Case 7.8 Is that all that happened?

• We can recall two cases of neurogenic low back pain from relatively benign
mechanisms. A fellow resident of ours in his late twenties was jogging
along the sidewalk when he stepped in a small ditch in the pavement.
He developed low back pain from this incident and did not make much
of it until he developed a foot drop. A subsequent MRI showed a large
disk herniation and he underwent back surgery.
• A 32-year-old nurse at our hospital who had no prior history of back
problems came to the ED with low back pain. The pain started immedi-
ately after she had bent over to pick up some clothes. She had weakness
and pain in her left leg and had numbness in her left fourth and fifth toes.
She did not have any bowel or bladder problems and had normal rectal
tone. An emergent MRI of the lumbosacral spine showed a large disk
herniation at L5-S1. The patient had emergent surgery and did well
subsequently.
• These two cases remind us that neurogenic low back pain may result
from minor trauma. The severity of spinal injury and pain is certainly
out of proportion to the actual trauma. Therefore, we must perform a
detailed neurologic examination and look for objective evidence of
neurogenic injury in every patient with low back pain.

Case 7.9 Is the Coumadin patient bleeding?

• Starr presents a case, in Cortlandt Forum, of low back pain that represents
one of an emergency physician’s worst nightmares.9 A 78-year-old woman
with a history of atrial fibrillation and Coumadin use saw her cardiolo-
gist. Although he performed an echocardiogram, which showed an atrial
thrombus, he was distracted before he could order a prothrombin time
(PT).
• Two weeks later, she telephoned him to tell him that she was having easy
bruising and nosebleeds. He told her to come to the office the following
day, at which time he ordered a PT. The patient, however, was distracted
this time and never got it done. A day later when the cardiologist was
out of town and his partner was covering for him, the patient called
again to say that she had a large bruise on her forehead. The covering
physician instructed her to stop the Coumadin and get a PT drawn the
next day. The PT was prolonged at 35 seconds, so he gave her further
instructions to go to the emergency department for a Vitamin K injection.
She received her shot in the ED and had another PT drawn, which was
30 seconds.

continued
130 Learning from medical errors: clinical problems

• Not long after returning home, she developed severe low back pain, which
prompted her to return to the ED. She was examined by the ED physician
and given a shot of Toradol and discharged with pain medicines. When
she awoke the next day, she was a paraplegic. A CT scan in the ED showed
a large epidural hematoma compressing her spinal cord at the second
lumbar vertebrae. Her neurologic injury did not improve with surgical
decompression.
• The patient filed a lawsuit a few weeks later against the cardiologist, his
partner, and the ED physicians. Although the first cardiologist had failed
to check the patient’s PT at the initial visit, he was not found at trial to
be negligent. This was partly due to the plaintiff expert witness who
faulted the other physicians for failing on multiple opportunities to correct
the patient’s coagulopathy. The other defendants, consequently, were
held responsible for a jury award of $12.2 million with an additional
$3 million in interest. The jury, in this case, did not consider that the
patient herself missed a golden opportunity to have her PT checked before
the development of the low back pain.
• We stressed earlier about using caution in patients taking anticoagulants
with traumatic low back pain. The patient in this case, however, had no
history of low back trauma. Instead, she had a coagulopathy along with
clinical manifestations of it (bruising, nosebleeds). Hence there was
evidence of spontaneous bleeding and a history of trauma is not required
to raise the suspicion of an epidural hematoma.

References
1 Hamilton GC, Sanders AB, Strange GR et al. (2003) Emergency Medicine: an approach to
clinical problem-solving (2e). Saunders, Philadelphia, Pennsylvania, 483.
2 Hamilton GC, Sanders AB, Strange GR et al. (2003) Emergency Medicine: an approach to
clinical problem-solving (2e). Saunders, Philadelphia, Pennsylvania, 485.
3 Schwartz GR (1999) Principles and Practice of Emergency Medicine (4e). Lippincott
Williams & Wilkins, Philadelphia, Pennsylvania, 1291.
4 Quiles M, Marchisello J and Tsairis P (1978) Lumbar adhesive arachnoiditis. Spine. 3:
45–50.
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