BEWARE sudden onset thoracic back pain

Just reviewed a case last week of a person who presented with back pain (thoracic) as the sole manifestation of an aortic dissection. No chest pain, belly pain, etc. JUST severe, acute, thoracic back pain.

Keys to staying out of trouble:

• Any sudden onset pain should be explained. Musculoskeletal pain doesn't normally present like this. Look for risk factors like HTN. If a person with HTN (even if not that high in the ED) presents with acute, severe, thoracic back pain the diagnosis of dissection should at the very least be considered.
• The key to making the diagnosis begins with thinking about the diagnosis.
• At the very least, include aortic dissection in EVERY patient you see with back pain, especially if sudden onset. I am not talking about the 95%+ people who don't really have anything wrong with them and who stumble into urgent care asking (begging) for Percocet.
• Sudden onset back pain should also prompt consideration for a AAA
• Just like all else in Emergency Medicine, always ask yourself if a "worst case scenario" could be present?, and the list for acute back pain is pretty short: dissection, AAA, fracture (by history), cancer, infection. Most of these, however, do not present acutely.

References

Elefteriades, 2008