Emergency Department Care

Patients should lie in a position in which they are most comfortable. Muscle relaxants are of limited use, and clinical studies have not proven their efficacy. This class includes benzodiazepines, methocarbamol, and cyclobenzaprine. Patients should be warned that all of these drugs are sedating. Opioids provide very effective acute pain relief, but they should not be used in patients with chronic pain. Salicylates, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs) all have been used in the treatment of pain from lumbar disc disease, but none of these has been shown to be superior to the others. Acetaminophen lacks anti-inflammatory activity.^{[13, 14]}

Of 76 patients who presented to an emergency department with low back pain, 42 (55%) had resolution or return of pain to baseline with conservative management; 18 (24%) had improvement with intervention (epidural steroid injection or kyphoplasty); 8 (11%) improved with surgery; and 8 (11%) had persistent pain.^[15]

Medical Care

Bed rest is not recommended most of the time. The exception is for patients whose pain is so severe that they cannot ambulate. Prolonged immobilization may worsen pain and extend recovery time. Strict bed rest should never exceed 2 days. Patients should be encouraged to begin limited activity as soon as possible.

Whether spinal manipulation (ie, chiropractic care) improves the rate of recovery in patients with disc disease is controversial.

Multiple surgical techniques have been used in patients with disc herniation who have not responded to 6 weeks of conservative therapy. These surgical techniques include discectomy, spinal fusion, and injection of chymopapain.^{[16, 17, 18, 19]}

The Spine Patient Outcomes Research Trial (SPORT) failed to find any statistical superiority of surgical treatment versus conservative treatment for lumbar disc herniation.^{[20, 21]} This occurred because the study design allowed crossover of treatment based on the patients' preference. These findings suggest that, in most cases, there is no clear reason to advocate for surgery apart. Patient choice appears to be the most important predictive factor.

Guidelines

Björnsdóttir S, Jónsson S, Valdimarsdóttir U. Functional limitations and physical symptoms of individuals with chronic pain. Scand J Rheumatol. 2012 Nov 6. [QxMD MEDLINE Link].
[Guideline] Patel ND, Broderick DF, Burns J, et al. ACR Appropriateness Criteria Low Back Pain. J Am Coll Radiol. 2016 Sep. 13 (9):1069-78. [QxMD MEDLINE Link].
Edwards J, Hayden J, Asbridge M, et al. Prevalence of low back pain in emergency settings: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2017 Apr 4. 18 (1):143. [QxMD MEDLINE Link].
Farshad-Amacker NA, Farshad M, Winklehner A, Andreisek G. MR imaging of degenerative disc disease. Eur J Radiol. 2015 Sep. 84 (9):1768-76. [QxMD MEDLINE Link].
Gregory DS, Seto CK, Wortley GC, Shugart CM. Acute lumbar disk pain: navigating evaluation and treatment choices. Am Fam Physician. 2008 Oct 1. 78(7):835-42. [QxMD MEDLINE Link].
Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA. 2003 Jun 4. 289(21):2810-8. [QxMD MEDLINE Link].
Soares Oliveira I, da Silva T, Costa LOP, Medeiros FC, Oshima RKA, de Freitas DG, et al. The Long-Term Prognosis in People With Recent Onset Low Back Pain From Emergency Departments: An Inception Cohort Study. J Pain. 2021 May 21. [QxMD MEDLINE Link].
Deen HG Jr. Diagnosis and management of lumbar disk disease. Mayo Clin Proc. 1996 Mar. 71(3):283-7. [QxMD MEDLINE Link].
Deyo RA. Diagnostic evaluation of LBP: reaching a specific diagnosis is often impossible. Arch Intern Med. 2002 Jul 8. 162(13):1444-7; discussion 1447-8. [QxMD MEDLINE Link].
[Guideline] ACR Appropriateness Criteria Low Back Pain. ACR.org. Available at https://acsearch.acr.org/docs/69483/Narrative/. 2021; Accessed: August 7, 2021.
Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994 Jul 14. 331(2):69-73. [QxMD MEDLINE Link].
El Barzouhi A, Verwoerd AJ, Peul WC, Verhagen AP, Lycklama À Nijeholt GJ, Van der Kallen BF, et al. Prognostic value of magnetic resonance imaging findings in patients with sciatica. J Neurosurg Spine. 2016 Feb 12. 1-8. [QxMD MEDLINE Link].
Radcliff K, Freedman M, Hilibrand A, Isaac R, Lurie JD, Zhao W, et al. Does Opioid Pain Medication Use Affect the Outcome of Patients with Lumbar Disk Herniation?. Spine (Phila Pa 1976). 2013 Apr 15. [QxMD MEDLINE Link].
Eskin B, Shih RD, Fiesseler FW, Walsh BW, Allegra JR, Silverman ME, et al. Prednisone for emergency department low back pain: a randomized controlled trial. J Emerg Med. 2014 Jul. 47 (1):65-70. [QxMD MEDLINE Link].
Rao S, Rao S, Harvey HB, Avery L, Saini S, Prabhakar AM. Low back pain in the emergency department-are the ACR Appropriateness Criteria being followed?. J Am Coll Radiol. 2015 Apr. 12 (4):364-9. [QxMD MEDLINE Link].
Carragee E. Surgical treatment of lumbar disk disorders. JAMA. 2006 Nov 22. 296(20):2485-7. [QxMD MEDLINE Link].
Deyo RA, Gray DT, Kreuter W, et al. United States trends in lumbar fusion surgery for degenerative conditions. Spine. 2005 Jun 15. 30(12):1441-5; discussion 1446-7. [QxMD MEDLINE Link].
Dullerud R, Nakstad PH. CT changes after conservative treatment for lumbar disk herniation. Acta Radiol. 1994 Sep. 35(5):415-9. [QxMD MEDLINE Link].
Willems PC, Staal JB, Walenkamp GH, de Bie RA. Spinal fusion for chronic low back pain: systematic review on the accuracy of tests for patient selection. Spine J. 2012 Nov 2. [QxMD MEDLINE Link].
Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006 Nov 22. 296(20):2441-50. [QxMD MEDLINE Link].
Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA. 2006 Nov 22. 296(20):2451-9. [QxMD MEDLINE Link].
[Guideline] Patel ND, Broderick DF, Burns J, et al. ACR Appropriateness Criteria Low Back Pain. J Am Coll Radiol. 2016 Sep. 13 (9):1069-78. [QxMD MEDLINE Link].
Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017 Apr 4. 166 (7):514-530. [QxMD MEDLINE Link].
[Guideline] Bernstein IA, Malik Q, Carville S, Ward S. Low back pain and sciatica: summary of NICE guidance. BMJ. 2017 Jan 6. 356:i6748. [QxMD MEDLINE Link].
[Guideline] American Pain Society Low Back Pain Guideline Panel. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976). 2009 May 1. 34 (10):1066-77. [QxMD MEDLINE Link].
Patel S, Psychol C, Friede T, Froud R, Evans DW, Underwood M. Systematic review of randomised controlled trials of clinical prediction rules for physical therapy in low back pain. Spine (Phila Pa 1976). 2012 Nov 5. [QxMD MEDLINE Link].
Son S, Lee SG, Kim WK, Ahn Y, Jung JM. Disc height discrepancy between supine and standing positions as a screening metric for discogenic back pain in patients with disc degeneration. Spine J. 2021 Jan. 21 (1):71-79. [QxMD MEDLINE Link].
Frost H, Lamb SE, Doll HA, et al. Randomised controlled trial of physiotherapy compared with advice for low back pain. BMJ. 2004 Sep 25. 329(7468):708. [QxMD MEDLINE Link].
Gilbert FJ, Grant AM, Gillan MG, et al. Low back pain: influence of early MR imaging or CT on treatment and outcome--multicenter randomized trial. Radiology. 2004 May. 231(2):343-51. [QxMD MEDLINE Link].
Juch JNS, Maas ET, Ostelo RWJG, et al. Effect of Radiofrequency Denervation on Pain Intensity Among Patients With Chronic Low Back Pain: The Mint Randomized Clinical Trials. JAMA. 2017 Jul 4. 318 (1):68-81. [QxMD MEDLINE Link].

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Author

Jere F Baldwin, MD Medical Director, Department of Emergency Medicine, Mercy Hospital Port Huron

Jere F Baldwin, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Emergency Physicians, American Medical Association, Michigan State Medical Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey Horwitz, DO Director, Assistant Clinical Professor, Department of Emergency Medicine, North Shore University Hospital at Forest Hills

Jeffrey Horwitz, DO is a member of the following medical societies: Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Mark S Slabinski, MD, FACEP, FAAEM Vice President, USACS Central

Mark S Slabinski, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Ohio State Medical Association

Disclosure: Nothing to disclose.

Sections Lumbar (Intervertebral) Disc Disorder Management in the ED
Overview
Presentation
DDx
Workup
Treatment
Guidelines
Medication
References

Lumbar (Intervertebral) Disc Disorder Management in the ED Treatment & Management

Emergency Department Care

Medical Care

References

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