When is back pain an emergency?

If back pain is a medical emergency, you usually feel intense and sudden symptoms such as:

• Difficulty standing or walking

• Loss of bowel or bladder control

• Loss of consciousness

• Pain that extends from the lower back around to your abdomen

• Sudden numbness in your pelvic region or in one or both legs

If you experience any of these symptoms, seek emergency care or call 911.

Most cases of back pain are nothing to worry about and will improve within a few weeks. Less than 1% of people with low back pain have ‘red flag’ symptoms that mean you should seek medical attention as soon as possible such as:

• If your back pain has not started to improve after 6 weeks.

Most cases of back pain should settle relatively quickly so if you are still experiencing back pain after 6 weeks, seek a medical opinion. This may be a sign of a slipped disk or a more significant back problem.

• If your back pain started after a significant fall or accident.

Trauma to the spine can cause fractures of the vertebrae (the backbones), including in young and strong people, although there may be other causes of fractures as well. Examples of these are weak bones in the elderly (known as insufficiency fractures), stress fractures due to repeated minor trauma - including various occupations or sports - and pathological fractures that occur in bones weakened by cancer.

• If you have a history of cancer including prostate, breast, lung or bone cancer.

This may weaken or even destroy some vertebrae and cause acute severe back pain.

• If you have sciatica affecting both legs, numbness around your bottom or problems with your bowel or bladder control.

If a nerve gets pinched in the back this can cause pain, pins and needles, and numbness, radiating down the leg, known as ‘sciatica’ and is most commonly caused by a ‘slipped disk’ or arthritic spinal joints pressing on a nerve. A more serious problem is known as cauda equina syndrome where the nerves at the bottom of the back become squashed. This causes lower back pain, difficulty in peeing (and sometimes bowel problems too), weakness in one or both legs and numbness around the rectum and between the legs called the ‘saddle’ area. This is a medical emergency and requires urgent medical attention.

• If you are feeling generally unwell with a fever, and no other flu-like symptoms.

This is because of the possibility of infection developing in your vertebrae, known as osteomyelitis. Although rare, this occurs when infection from one part of the body spreads into your back and causes a high temperature, feeling very unwell and sometimes redness in the back.

• If you’ve been taking steroid tablets for several months.

Prolonged use of steroid tablets - especially at high doses - can cause the backbones to thin and become weak which in turn can cause them to collapse or break.

• If the pain travels up your back or into your chest.

This can be a sign of an abdominal aortic aneurysm (AAA). This is caused by a weakness in the main artery of the body that runs from the heart down into your abdomen, called the aorta. It may cause constant, stabbing pain in the lower back and abdomen along with a fast pulse, cold sweats and shallow breathing. Seek urgent medical attention if this occurs.

• If you’re aged under 45 and get severe back pain and stiffness first thing in the morning every morning, lasting for 30 minutes or more, and this has persisted for 3 months or more - often movement will make it feel better.

This can be a sign of an inflammatory disorder where earlier treatment can prevent the condition from progressing.

• If you’re losing weight for no obvious reason.

Losing weight for no obvious reason should always be investigated. There are many possible reasons why this can happen and not all of them are serious but these can include cancer, thyroid problems, diabetes and liver and kidney problems. Speak with your doctor if this is happening to you and they can arrange some simple blood tests initially.

If you have any of the above features associated with your back pain your doctor may refer you directly for investigations or to a specialist to identify the cause for your back pain.

If you get back pain and you are under 18 or over 50 years old, or your back pain wakes you up from sleep, then you should also request an urgent appointment with your doctor.

The treatment for your back pain depends on what kind of pain you have. Acute back pain usually gets better without any treatment, but you may want to take painkillers such as acetaminophen or ibuprofen to help ease the pain. Exercise and surgery are not usually needed to treat acute back pain.

Painkillers

Chronic back pain is usually treated with painkiller (analgesic) medication – these include over-the-counter drugs such as acetaminophen and nonsteroidal anti-inflammatory (NSAID) tablets like ibuprofen as well as topical analgesics like pain relief creams and gels that can be rubbed onto the skin over the site of pain.

NSAIDs

Your doctor may prescribe stronger NSAIDs if necessary, as well as muscle relaxants and some antidepressants, that can be helpful with chronic back pain, although these do not work for every type of back pain.

Remember - do not give aspirin (acetylsalicylic acid) or aspirin-containing products to anyone 18 years or younger because of the risk of a serious illness called Reye's syndrome. Always take NSAIDs with food or milk to prevent stomach irritation and do not give NSAIDs to anyone with:

• NSAID-induced asthma

• Increased risk of bleeding, such as ulcer disease, a bleeding disorder, if taking blood thinners (anticoagulants), or following surgery, significant trauma or major dental work

• An allergy to NSAIDs

Alternative treatments

If back pain is not relieved by medication, some people try complementary and alternative treatments. The most common of these treatments are manipulation such as chiropractic or osteopathic treatment, transcutaneous electrical nerve stimulation (TENS) treatment where a small box over the painful area sends mild electrical pulses to nerves to help block pain signals, and acupuncture may also be helpful in some people.

When surgery is required

Most people with chronic back pain do not need surgery and this is only required if other treatments do not work. You may need surgery if you have a slipped disk – here, one or more of the disks that cushion the bones of the spine are damaged and the jelly-like center of the disk leaks and presses on a spinal nerve causing pain. Other conditions that may require surgery include spinal stenosis where the spinal canal becomes narrow and causes pain, spondylolisthesis – where one or more bones of the spine slip out of place and osteoporosis where weakening of the bones causes them to crumble and occasionally fracture.

If you are being considered for back surgery, your surgeon will consider these points as important reasons to go ahead:

• You are in reasonably good health

• Your back pain significantly affects your quality of life

• If you have leg weakness or numbness

• If you have problems with your bladder or bowels

• If you have difficulty standing or walking

• If medication and other treatments have been tried and found to be ineffective

When back pain is an emergency - such as when it is caused by a tumor, a severe infection, or cauda equina syndrome - surgery is needed right away to ease the pain and prevent more problems from occurring.

Remember - if you are in any doubt about why you have back pain or are concerned it may be getting worse or be due to a serious problem, always seek the advice of your healthcare professional as soon as possible.