VA AM Report: “Needle in a Haystack”

Title courtesy of Goop. Awesome case presented by the inimitable Michelle Matzko, with a case of legit spinal GOUT. Crazy.

Back pain in the clinic,

Big picture on back pain in the clinic plus some pearls: Acute low back pain is one of the most common reasons people seek medical care in the US, cough being the most common.

Table 2.

Red Flags for Serious Etiologies of Acute Low Back Pain (technically age>50 is one as well though very sensitive)

Possible etiology History findings Physical examination findings


Strong: Cancer metastatic to bone Intermediate: Unexplained weight loss

Weak: Vertebral tenderness, limited spine range of motion

Weak: Cancer, pain increased or unrelieved by rest

Cauda equina syndrome

Strong: Bladder or bowel incontinence, urinary retention, progressive motor or sensory loss

Strong: Major motor weakness or sensory deficit, loss of anal sphincter tone, saddle anesthesia

Weak: Limited spine range of motion


Strong: Significant trauma related to age*

Weak: Vertebral tenderness, limited spine range of motion

Intermediate: Prolonged use of steroids

Weak: Age older than 70 years, history of osteoporosis


Strong: Severe pain and lumbar spine surgery within the past year

Strong: Fever, urinary tract infection, wound in spine region

Intermediate: Intravenous drug use, immunosuppression, severe pain and distant lumbar spine surgery

Weak: Vertebral tenderness, limited spine range of motion

Weak: Pain increased or unrelieved by rest

note: Presence of one or two weak or intermediate red flags may warrant observation because few patients will be significantly harmed if diagnosis of a serious cause is delayed for four to six weeks. Presence of any strong red flag warrants more urgent workup and probable referral to a spine subspecialist.

*ā€”Fall from a height or motor vehicle crash in a young patient, minor fall or heavy lifting in a patient with osteoporosis or possible osteoporosis.

Information from references 5, 6, and 8.

We all know the red flags, but what do you do if there are no red flags? Most back pain will resolve within six weeks with conservative management like activity modification (NOT BED REST), NSAIDS and Tylenol. For pain that has not resolved it is then reasonable to prescribe formal physical therapy, and again most back pain will resolve over the next 6-12 weeks.

Exam maneuvers: With an anterior disc herniation extension theoretically relieves the pressure on the disk and improves pain, whereas extension in any lumbar stenosis worsens compression of the nerve roots and thus symptoms. Bharat pointed out the “shopping cart sign” with lumbar stenosis, that slight forward flexion relieves the pain of lumbar stenosis as one would while pushing your shopping cart.

Spinal Gout: LT has seen three cases so you know, super common disease. It’s actually interesting, among pts w/ tophaceous gout and persistent symptoms/pain, one study found radiographic evidence of spinal gout to be 35%, though few of those patients actually had back pain. It can mimic metastatic disease or infection/epidural abscess, definitive diagnosis can often only be obtained through examination of surgical specimens and/or IR guided aspirate of the fluid around the spinal cord which will show no organisms and may contain crystals. Attached here is a case report goop co-authored in JHM about a similar case. jhm-2013-a-multifaceted-case


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