Emergency surgical management of nontraumatic pathologic spinal pain diagnosed in the emergency department

BACKGROUND: This study aimed to evaluate patients who presented to the emergency department with non-traumatic back or lumbar pain, without new-onset neurological deficits or cauda equina syndrome. Because of inadequate response to medical treatment, patients underwent imaging of the affected region and subsequently required emergency neurosurgical intervention. METHODS: We included patients aged ≥18 years who presented to the emergency department with back or lumbar pain, experienced no pain relief despite analgesic treatment, underwent imaging of the affected region, and were referred for emergency surgical treatment by the neurosurgery department based on imaging findings. Patients presenting with trauma, new-onset neurological deficits, or a history of prior spinal surgery were excluded. RESULTS: The study included 35 patients with a mean age of 65.51 years (range: 42–82). Among them, 11.4% (n=4) had chronic kidney disease, 37.14% (n=13) had diabetes mellitus, 22.8% (n=8) had a history of cancer, and 22.8% (n=8) had a family history of cancer. No red flag findings other than cancer-related risk factors were identified. The primary clinical indicator of underlying pathology was persistent pain despite analgesic treatment. Advanced diagnostic evaluation revealed pathological fractures in 77.1% of patients (n=27), spinal abscesses in 14.2% (n=5), and spondylodiscitis in 8.5% (n=3); all patients underwent emergency surgical treatment. Among patients with pathological fractures, histopathological examination demonstrated osteoporotic fractures in 59.2% (n=16) and metastatic fractures in 40.8% (n=11). Notably, all spinal metastases led to the initial diagnosis of cancer, and only two of these patients presented with red flag symptoms. CONCLUSION: Patients without spinal emergencies or red flag symptoms may still require emergency surgical intervention. Therefore, diagnostic and evaluation algorithms should be developed for this patient population. We believe that pain severity scores may play an important role in such algorithms.