The Skeptics Guide to Emergency Medicine Global

Date: October 26, 2023

Reference: Jones et al. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial placebo-controlled trial. Lancet July 2023

Guest Skeptic: Dr. Sergey Motov is an Emergency Physician in the Department of Emergency Medicine, Maimonides Medical Center in New York City. He is also one of the world’s leading researchers on pain management in the emergency department, specifically the use of ketamine. His twitter handle is @PainFreeED.

Case: A 37-year-old man without a significant past medical history presents to the emergency department (ED) with a chief complaint of lower back pain that started three days prior to the ED visit after unloading a truck with furniture. He states that pain is severe (7/10 in intensity), sharp, constant, non-radiating, and is exacerbated by any movement. The patient is unable to go to work due to pain and is experiencing severe limitations in his daily activities. He denies any weakness or numbness of the lower extremities or bowel or bladder dysfunction. You perform a physical examination and note prominent tenderness to palpation at bilateral lumbar paraspinal regions with normal neuro-vascular examination. You engage the patient in shared decision making about his most likely diagnosis (muscle strain) and treatment approach such as a short course of non-steroidal anti-inflammatory drugs (Ibuprofen) and gradual physical activity as tolerated. The patient, however, believes that ibuprofen will not touch his pain and insists on receiving an opioid-containing medication.

Background: Low back pain and neck pain are extremely common conditions worldwide [1]. We have covered the issue of back pain several times on the SGEM including:

SGEM#87:Let Your Back Bone Slide (Paracetamol for Low-Back Pain)

SGEM#173: Diazepam Won’t Get Back Pain Down

SGEM#240: I Can’t Get No Satisfaction for My Chronic Non-Cancer Pain

SGEM#304: Treating Acute Low Back Pain – It’s Tricky, Tricky, Tricky

SGEM#366: Relax, Don’t Do It – Skeletal Muscle Relaxants for Low Back Pain

Back pain and neck pain are leading causes of disability on a global scale [2,3]. The substantial disability burden imposes enormous costs both directly on healthcare systems, and indirectly through productivity losses [4,5].

Not only are these conditions common and painful they are difficult to treat. Many pharmacologic treatments have been tried with limited efficacy.

Acetaminophen (Williams et al Lancet 2014)

Muscle relaxants (Friedman et al JAMA 2015)

NSAIDs (Machado et al  Ann Rheum Dis 2017)

Steroids (Balakrishnamoorthy et al Emerg Med J 2014)

Benzodiazepines (Friedman et al Ann Emerg Med 2017)

Many non-pharmacologic therapies have also been tried with limited efficacy.

Cognitive Behavioral Therapy and mindfulness (Cherkin et al JAMA 2016)

Chiropractic (Paige et al JAMA 2017)

Physical therapy (Paolucci et al J Pain Research 2018)

Acupuncture (Colquhoun and Novella Anesthesia and Analgesia 2013)

One treatment modality, opioids, can be effective but comes with very real potential harms. The American College Physicians (ACP) has a 2017 policy on guidelines for treating non-radicular low back pain (Qaseem et al Annals of Int Med). Their third recommendations states:

Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence)

The American College of Emergency Physicians (ACEP) has addressed the issue of opioid use in patients being discharged home after an acute episode of pain. They give a Level C Recommendations saying:

Do not routinely prescribe, or knowingly cause to be co-prescribed, a simultaneous course of opioids and benzodiazepi...

Date: November 30th, 2022

Reference: Johnson et al. One-year outcome of surgery compared with immobilization in a cast for adults with an undisplaced or minimally displaced scaphoid fracture: A meta-analysis of randomized controlled trials. Bone Joint J 2022

Guest Skeptic: Dr.Matt Schmitz is an Orthopaedic Surgeon specializing in Adolescent Sports Medicine and Young Adult Hip Preservation.

DISCLAIMER: THE VIEWS AND OPINIONS OF THIS BLOG AND PODCAST DO NOT REPRESENT THE UNITED STATES GOVERNMENT OR THE US MILITARY.

Case: A 32-year-old male construction worker presents to the emergency department (ED) after falling on his right dominant hand. He has swelling in his distal radius, snuffbox tenderness, decreased range of motion and is neurovascularly intact distal to the injury. X-rays demonstrate a minimally displaced midwaist fracture of the scaphoid. He’s got a big job coming up in a couple of months and can’t work with a cast. He asks if surgery would be a better option?

Background: Fractures of the scaphoid are the most common carpal fractures presenting to the emergency department (ED). Initial x-rays pick up 17% with only 7% more being identified on follow-up x-rays (1,2).

The classic history for a scaphoid fracture is a fall on outstretched hand (FOOSH). Clinicians need to be careful in taking the history because other mechanisms that hyperextend the wrist like a motor vehicle collision while holding the steering wheel can also apply enough force to fracture the scaphoid.

Physical examination of patients with a FOOSH injury include palpating for snuff box tenderness. In a systematic review and meta-analysis (SRMA) by Carpenter et al they were only able to find six studies with a total of 170 patients found in the world’s literature looking at snuff box tenderness.  The evidence had a substantial amount of heterogeneity (3). The LR- to rule out a scaphoid fracture was 0.15 for snuffbox tenderness which is moderate evidence. However, it had a very wide 95% confidence interval around the point estimate (95% CI; 0.05 to 0.43). 

There are many other physical exam maneuvers like thumb compression, vibration pain, clamp sign, ulnar deviation pain, radial deviation pain, scaphoid tubercle pain, and resisted supination pronation. None of these have a LR- low enough (<0.1) to reliably rule out a scaphoid fracture.

We mentioned x-rays were unreliable as well to rule-out a scaphoid injury. Other imaging modalities like bone scan, ultrasound and CT scan have been used but found to be lacking in accuracy. The best imaging test is an MRI.

* Initial X-ray 0.24 (0.07–0.79)

* Follow-up X-ray 0.67 (0.50–0.89)

* Bond Scan 0.11 (0.05–0.23)

* Ultrasound 0.27 (0.13–0.56)

* CT Scan 0.23 (0.16–0.34)

* MRI 0.09 (0.04–0.19)

Emergency physicians can use clinical decision instruments to help in diagnosing certain conditions. There are many validated instruments for fractures such as the Ottawa Ankle Rule (SGEM#3), Ottawa Knee Rule (SGEM#5) and the Canadian C-Spine Rules (SGEM#232). There is no validated clinical decision instrument to help ED physicians accurately rule in or out a scaphoid fracture (4,5).

There is not a diagnostic dilemma in this case. The question is does the scaphoid fracture need to be treated operatively or non-operatively.

The vast majority (90%) of scaphoid fractures are non-displaced and treated with cast immobilization (6). Displaced fractures increase the risk of non-union from 14% to 50% (7,8,9). If left with a non-union,