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Bill Klaproth (Host): Low back pain is extremely common. It affects millions of individuals each year and hundreds of millions of dollars are spent on lost work and medical care. If you are suffering from back pain, where should you go? Here to talk with us about that is Dr. Nick Colovos, Assistant Professor at Emory School of Medicine and Department of Emergency Medicine, Interim Chief Quality Officer for the Physician Group Practices at Emory Healthcare. Dr. Colovos thank you for your time. So, almost everyone has at least one episode of back pain sometime in their life, a twinge here a tweak there; but when is it time to see the doctor?

Nick Colovos, MD, MBA, FACEP (Guest): Yeah that’s a great question and I think one of the things that we look at from the physician point of view is that when we evaluate an individual with low back pain; we really look at several red flags. Those red flags help us identify or at least help us consider whether somebody has sustained a fracture or break in their back, whether there’s a potential cancer or tumor or infection of the spine. And the red flags that we typically are looking for are things like fever associated with the back pain. Have you had a recent trauma, a fall or mechanism of injury from a motor vehicle accident that could be causing that? Are you developing numbness or tingling in one of your legs or arms? Most people have experienced this when they cross their legs and their foot falls asleep. That foot falling asleep is because we are pinching a nerve. Well if your legs aren’t crossed and you are having those symptoms; that could be a pretty significant issue that we have to address. In addition, the loss of bowel or bladder function is extremely important and can indicate that we are having some neurological issues. And any patient that has a history of cancer or may have a suppressed immune system, osteoporosis or is on chronic steroids we also have a substantial concern for what is the cause of their back pain.

Bill: So, is there ever a time then that someone should seek urgent care or the ER for back pain?

Dr. Colovos: I think that the principle thing that most people would want to look at is we have all experienced what we define in medicine is that mechanical back strain. You went out and you mowed the lawn, you did an exercise program that was new, you did some lifting at work and you have just the achy soreness in the back area. Those types of symptoms can often be managed at home or with your primary care physician and they can also be taken care of at an Urgent Care Center where further evaluation can be made. However, typically, when pain in the back persists for more than six weeks and most people’s back pain will last for just under six weeks and goes away. If it’s lasting for longer than six weeks; that’s usually the time to seek medical help through either your primary care physician or the Urgent Care. If you have one of those red flags I mentioned in association with that back pain; that’s probably the time to go to the Emergency Department because you may need and require some advanced imaging.

Bill: Right, so you were just mentioning the normal back strain and pain from mowing the lawn or starting a new exercise program. But for some of those other symptoms you were mentioning and some other conditions like cancers or kidney conditions or even aneurysms; are the symptoms different? Are there certain things we should be looking out for?

Dr. Colovos: There are. Certainly, we look for things that if it is a kidney type infection causing the pain, a patient may see some blood in their urine or red discoloration to their urine. They may have their pain localized on one side of their back or the other. Patients that are having back pain along with abdominal pain could be a serious condition such as an abdominal aortic aneurism. The challenge in medicine is that folks often present with variability in how these symptoms present. We would like it if everybody red the book and presented exactly like it says in our textbooks, but they don’t. And so, when you have the symptoms associated with back pain and you have those symptoms of fever, a recent trauma, numbness or tingling of an extremity, loss of feeling, a foot drop potentially or loss of bladder or bowel control; those are going to be indications that we need to take a more serious look and the severity of the issue may be such that the ER is the appropriate course of action to take.

Bill: Okay so as you are talking about this I’m thinking that’s all great information and you already told us about seeking Urgent Care but or ER, but I feel like how do we know? Should we go to – what should it be Urgent Care, ER or doctor? I feel like I don’t know which one is which. What should we do?

Dr. Colovos: I think in most circumstances when you develop your back pain, if it’s something that’s kind of associated with an activity that you may have recently performed; it certainly is probably going to be on that musculoskeletal category. If you have had a recent fall or trauma or something else, then it could be a fracture or break in the back. Typically, like I said, most back pain will resolve on its own about 90% of back pain gets better within about six weeks regardless of what we do. However, in making that decision between an Urgent Care and an Emergency Room; if you are having back pain, you are not having the fever, you are not having the numbness or other associated symptoms; going to your primary care or the Urgent Care Center would be probably the most appropriate thing to do. If you are having just intermittent symptoms, it’s okay to go to your primary care and to the Urgent Care. However, if you start developing those other red flags that we mentioned that would be the opportune time to seek assistance at the ER.

Bill: Alright, got it. And you mentioned most back pain resolves itself after six weeks. So, if six weeks go by and you still have that pain; is that when typically, you would go to the doctor and generally then is it physical therapy then for your back?

Dr. Colovos: It’s a possibility that might be a recommendation. But your doctor will certainly want to investigate a little bit more to help rule out any serious underlying cause. And so that may be some additional studies, CAT scans, MRIs, bloodwork, things of that nature. Any pain that’s lasting longer than six weeks usually is a trigger point for us to look and see well why is it going on longer and there could be anything from a herniated disk to some other malady that’s on there that we need to address and so, anything longer than six weeks should certainly get you in to medical help with your primary care physician to see what’s going on.

Bill: Well you have certainly helped us in understanding on whether to go to the ER, Urgent Care or make an appointment with the doctor. Dr. Colovos what else should we know about back pain and where to go?

Dr. Colovos: It’s a common symptom and people often will experience at least one or more episodes throughout their life. The challenge is trying to figure out the cause of it. And in most patients the cause is going to be mechanical in nature. They lifted something, they moved something, maybe started a new exercise program or some physical activity. The reality with it is, is we want to try to keep people on their feet, keep them moving, don’t go to bedrest. The days of bedrest are long since gone. That actually can worsen your back pain. However, if you have any symptoms associated with that back pain such as sudden back pain with fever, trauma that’s been related to it, numbness or loss of feeling in an extremity, loss of control of bladder or bowel function or any medical history of cancer or immune system suppression, osteoporosis or you have been on chronic steroids; those are going to be indicators that you need to get some attention immediately to be looked at, to make sure that your provider can help rule out any serious underlying cause.

Bill: And for some instant relief at home Dr. Colovos, is it a good idea to ice that area as soon as you can if you have that mechanical back strain that you were talking about?

Dr. Colovos: I think so. Decreasing the inflammation if you suddenly get it – decreasing the inflammation by putting a cool moist compress over that area or if you find that warm moist compresses work over that area, that may help as well. And wither of those two can be used. A lot of times we will advise that if it’s an initial injury you want to kind of cool the area off a little bit, decrease the inflammation and the cool moist compresses are the way to go. Make sure there’s a barrier between the source of cold and your skin because we don’t want to cause any frostbite or injury to the skin itself. Likewise, warm moist compresses may work very well, have good penetration and may help relax that area as well.

Bill: And you said rest generally is not good, so just getting in bed and laying flat for a long period of time is probably not the best treatment method?

Dr. Colovos: It is not the best treatment method. In fact, we really want people to stay mobile. I don’t expect you to go out and play for one of the Georgia football teams, but I certainly want you to continue to remain active. Mobility is important otherwise, we can get very stiff, very sore and it can further compromise or discomfort.

Bill: A doctor once told me motion is lotion. So, I guess you are right, keep moving. That’s a good thing. Well Dr. Colovos thank you so much for your time. For more information please visit www.emoryhealthcare.org, that’s www.emoryhealthcare.org. You’re listening to Advancing Your Health with Emory Healthcare. I’m Bill Klaproth. Thanks for listening.