1. A Pain in the Back COPYRIGHT © 2013, ALL RIGHTS RESERVED From the Publishers of

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3. Copyright © 2013 Dear Consult Guys; I need your advice in my care of a patient with back pain. I saw Mr. G earlier today for back pain. I last saw him 3 weeks ago for treatment of a “boil” located on his back. He had a low grade fever but otherwise seemed well. I advised him to do warm soaks and according to him the boil resolved…. Dear Consult Guys; I need your advice in my care of a patient with back pain. I saw Mr. G earlier today for back pain. I last saw him 3 weeks ago for treatment of a “boil” located on his back. He had a low grade fever but otherwise seemed well. I advised him to do warm soaks and according to him the boil resolved….

4. Copyright © 2013 He returned today with 3 days of back pain. He’s had no incontinence or lower extremity weakness. There was mild tenderness to palpation but his exam otherwise normal. He is a diabetic and his diabetes is well controlled. I’ve tried to be selective in ordering imaging tests so in this case rather than ordering an imaging test I initiated anti- inflammatory medical therapy and suggested that he see me in follow-up in 4 weeks. In thinking more about the case I am just not sure that not ordering an imaging study was correct. What would you guys have done? He returned today with 3 days of back pain. He’s had no incontinence or lower extremity weakness. There was mild tenderness to palpation but his exam otherwise normal. He is a diabetic and his diabetes is well controlled. I’ve tried to be selective in ordering imaging tests so in this case rather than ordering an imaging test I initiated anti- inflammatory medical therapy and suggested that he see me in follow-up in 4 weeks. In thinking more about the case I am just not sure that not ordering an imaging study was correct. What would you guys have done?

5. Copyright © 2013 ACP Guideline Published in 2011 http://annals.org/article.aspx?articleid=746774

6. Copyright © 2013 Back pain is very common A selective approach to back pain imaging is recommended Key Points

7. Copyright © 2013 Indications for immediate imaging Major risk factors for cancer as a cause Risk factors for spinal infection Evidence of cauda equina syndrome  Urinary retention  Fecal incontinence  Saddle anesthesia

8. Copyright © 2013 Mr. G Diabetic Boil 3 weeks ago Malaise Tenderness L3-L4

9. Copyright © 2013 Epidural abscess Identifiable portal of entry in 2/3  Spinal surgery  Epidural catheter  Skin – soft tissue infection  Hematogenous (iv drug use) Classic: fever + spine tenderness + neurologic  Most not classic MRI

10. Copyright © 2013 Consult Guys Replies Mr. G’s presentation suggests epidural abscess An MRI should be done

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