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How Often Do We Miss Serious Causes of Headache and Back Pain?

April 4, 2019

Written by Clay Smith

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In patients presenting to the ED with headache or back pain, very few return with serious, missed diagnoses after the initial evaluation.  Patients who are elderly, immunocompromised, or have preexisting neurological disease were at greater risk of missing serious conditions.

Why does this matter?
Headache and back pain are common reasons for ED visits, 2% and 3% of total ED visits, respectively.  Most patients don’t have anything serious.  In the minority of patients who do, missing a diagnosis is a major public health problem that can cause serious longterm morbidity or mortality.  How often, after sending these patients with potential neurological problems home, will we miss something really bad?

Did I miss something?  Probably not.
This was a retrospective review of nearly 3.5 million adults from 6 geographically diverse U.S. states who were discharged from the ED with nonspecific headache or back pain.  They were interested in what percentage returned to the ED with, “subsequent hospitalization for primary diagnosis of a serious neurologic condition or in-hospital death within 30 days of ED discharge.”  For headache, 0.5% (10,374 patients) met this primary outcome; 0.2% (2,850) of back pain patients did.  The most common missed diagnosis in headache patients was ischemic stroke followed by subarachnoid hemorrhage; spinal abscess (including epidural abscess) followed by cauda equina in back pain patients.  Factors associated with a greater risk of return with a bad outcome were the same for both headache and back pain: “advanced age, male sex, non-Hispanic white, and comorbidities (eg, neurologic disorders, HIV/AIDS, malignancy.”  For me, this means very few patients with headache or back pain who are discharged with a non-specific diagnosis after ED assessment will have a bad short-term outcome, but I need to be more cautious in the elderly, those with preexisting neurologic problems, and immunocompromised patients.  Even though the percentage of patients with presumed missed diagnoses was small, on a population scale, this still impacts a large number of people and warrants ongoing effort to reduce ED misdiagnoses.  However, there are limits.  Even MRI is falsely negative for stroke in up to 7% of patients.  Sadly, we will miss bad things.  Thankfully, that is rare.

Missed Serious Neurologic Conditions in Emergency Department Patients Discharged With Nonspecific Diagnoses of Headache or Back Pain.  Ann Emerg Med. 2019 Feb 20. pii: S0196-0644(19)30027-7. doi: 10.1016/j.annemergmed.2019.01.020. [Epub ahead of print]

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Reviewed by Thomas Davis

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