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FOCUSED SHIFT VIEW
Open full pathwayLow Back Pain
Most leave with advice — the task is finding the dangerous few.
Educational first-pass aid. Reassess the patient, confirm doses and use local protocols.
1 · First minutes
- Red-flag sweep: infection, cancer/MSCC, fracture, cauda equina, AAA.
- No imaging for non-specific pain under 6 weeks without red flags.
- Retention, saddle numbness, or bilateral weakness → emergency MRI.
2 · Escalate now if
- Urinary retention or saddle anesthesia
- Bilateral leg weakness or progressive deficit
- Fever or IVDU with spinal pain
- Cancer history, unexplained weight loss, night pain
- Significant trauma — or minor trauma in the osteoporotic/elderly
- Age >50 with new severe pain + vascular history
3 · Immediate workup
- Focused neuro mapping; post-void residual (bladder scanner) if retention is possible
- Vitals including temperature
- Bedside US if AAA is on the list
4 · Don’t miss
- Cauda equina syndrome
Saddle anesthesia, urinary retention/incontinence, bilateral leg weakness — emergency MRI + neurosurgery. Do not wait for a “complete” picture. - Metastatic cord compression
Cancer history + spinal pain or neurology — contact the MSCC pathway, MRI, and start dexamethasone 16 mg if there are neurological signs (NICE NG234). - Spinal epidural abscess / discitis
Fever, IVDU, immunosuppression, recent procedures, exquisite midline tenderness — MRI + antibiotics. Do not give steroids if infection is the leading diagnosis. - Pathologic fracture / malignancy
Cancer history, night pain, weight loss, age >50 — MRI; myeloma can have normal X-rays. - Rupturing / expanding AAA
Elderly vasculopath with back pain = AAA until excluded (bedside US/CTA).
5 · Disposition lane
Admit
Epidural abscess on IV antibiotics, pathologic fracture needing stabilization, intractable radicular pain, social issues.
Emergency MRI + neurosurgery/ortho/oncology
Cauda equina, MSCC, unstable fracture, spinal infection with neuro signs.