← All presentations

Low Back Pain

Most leave with advice — the task is finding the dangerous few.

LearnQuick referenceClinical practice

Your objective: explain the approach, recognize important warning signs, then test your recall.

Abbreviations explained
ACS
Acute coronary syndrome
OMI
Occlusion myocardial infarction
ECG
Electrocardiogram
PE
Pulmonary embolism
POCUS
Point-of-care ultrasound
QTc
QT interval corrected for heart rate
LBBB
Left bundle branch block
RBBB
Right bundle branch block
hs-cTn
High-sensitivity cardiac troponin
CTA
Computed tomography angiography
ICU
Intensive care unit
Filter

The jobMost leave with advice — the task is finding the dangerous few.

  1. Red-flag sweep: infection, cancer/MSCC, fracture, cauda equina, AAA.
  2. No imaging for non-specific pain under 6 weeks without red flags.
  3. Retention, saddle numbness, or bilateral weakness → emergency MRI.
  4. NSAIDs and activity, not bed rest or opioids-first.

>90% of ED back pain is non-specific mechanical disease.

The ED task is a red-flag sweep: infection, malignancy (including MSCC), fracture, cauda equina, and AAA. Below age 50 without red flags, imaging adds cost and radiation — not diagnosis.

Cauda equina syndrome Critical

Key: Saddle anesthesia, urinary retention/incontinence, bilateral leg weakness — emergency MRI + neurosurgery. Do not wait for a “complete” picture.

Metastatic cord compression Critical

Key: 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 Critical

Key: Fever, IVDU, immunosuppression, recent procedures, exquisite midline tenderness — MRI + antibiotics. Do not give steroids if infection is the leading diagnosis.

Pathologic fracture / malignancy Critical

Key: Cancer history, night pain, weight loss, age >50 — MRI; myeloma can have normal X-rays.

Rupturing / expanding AAA Critical

Key: Elderly vasculopath with back pain = AAA until excluded (bedside US/CTA).

Osteoporotic compression fracture Emergent

Key: Elderly, steroids, minimal or no trauma — X-ray, treat pain, brace per ortho. Not immediately life-threatening but easy to miss.

Inflammatory spondyloarthropathy Common

Key: Night pain, morning stiffness >30 min, improves with activity, onset <40 y — not an ED emergency; HLA-B27 and SI-joint MRI as outpatient.

Renal colic / pyelonephritis / pancreatitis Common

Key: Flank radiation, urinary symptoms — urinalysis, lipase, CT as indicated.

Mechanical / radicular pain (sciatica) Common

Key: Positional, dermatomal radiation, positive straight-leg raise — NSAIDs, stay active, no bed rest.

Tick what your patient has — the banner updates as you go.

Trauma? Osteoporosis or chronic steroids? Cancer history?

Red-flag screen

fever, weight loss, night pain, immunosuppression, IVDU

Neuro

leg weakness, saddle numbness, bowel/bladder changes

Inflammatory vs mechanical pattern (morning stiffness, activity response)

Recent spinal procedures or surgery

Midline tenderness (fracture/abscess) vs paraspinal (muscular)

Straight-leg raise; dermatomal power, sensation, reflexes

Perianal sensation and rectal tone when cauda equina is possible

Fever; abdominal and pulsatile-mass exam; CVA tenderness

Gait and overall neurologic observation

Bedside

  • Focused neuro mapping; post-void residual (bladder scanner) if retention is possible
  • Vitals including temperature
  • Bedside US if AAA is on the list

Labs

  • CBC, ESR/CRP for infection/malignancy screen; urinalysis
  • Myeloma screen (SPEP, calcium, creatinine) when age + red flags fit

Imaging

  • No imaging for non-specific pain <6 weeks without red flags (ACP 2017; NICE NG59)
  • Emergency MRI for cauda equina, abscess, or MSCC — do not delay for plain films
  • X-ray first for osteoporotic fracture screen
  • Bedside US/CTA when AAA is suspected
Medication safety reminder

Use this as a first-pass prompt; verify all medications, doses, concentrations, contraindications, weight, pregnancy status, and local protocols before administration.

Check indication, allergy, route, renal/hepatic risk, interactions, monitoring, and local formulary.

Discharge

  • Non-specific mechanical pain without red flags: NSAIDs/acetaminophen ± heat, stay active (no bed rest), return precautions and follow-up. Opioids-first is outdated.

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.

Use objective reassessment and the local pathway.

Before the next decision · reassess and hand over

Use these learning prompts with the presentation’s pathway. They are not discharge criteria.

  1. Reassess: compare symptoms, observations and examination with the initial assessment and response to treatment.
  2. Warning signs for Low Back Pain:
    • 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. Reconsider: check unresolved findings and alternative explanations, including the pitfalls below.
  4. Escalate: communicate deterioration, uncertainty or needs beyond the current setting.
  5. Plan the transition: identify outstanding results, responsibility for follow-up, patient understanding and specific return advice.
Review this presentation’s disposition pathway →Practice a handover →

Clinical Pearls

  • Most ED back pain is mechanical — the job is the red-flag sweep, not an x-ray for everyone.
  • Cauda equina: emergency MRI, do not wait for a complete saddle-anesthesia picture.
  • Elderly vasculopath with back pain = AAA until the aorta is seen.
  • NSAIDs plus activity beat bed rest and opioids-first (ACP; Chou JAMA 2023).

Pitfalls

  • Cauda equina with “only” retention and back pain — do not wait for full saddle numbness.
  • Dexamethasone is for MSCC, not discogenic CES and not for suspected epidural abscess.
  • Epidural abscess can mimic simple sciatica in IVDU/diabetics — ESR/CRP is cheap, MRI is decisive.
  • Myeloma X-rays look normal — escalate to MRI/SPEP if suspicion persists.
  • AAA presenting as back pain in the elderly is a killer misdiagnosis.
  • Bed rest and opioids-first are outdated — NSAIDs plus activity (ACP; Chou JAMA 2023).
PRACTICE REFRESHER

Rapid recall

Test your first action and the dangerous diagnoses before revealing the answer.

01 · First move

Before you scroll, what needs to happen first?

02 · Immediate threats

Name at least two diagnoses that cannot wait.

PRIVATE TO THIS DEVICE

Your learning note

Capture a weak point, a teaching pearl, or a question to take to your next shift.

Review schedule starts when marked reviewed
Weakness & FatigueAbdominal PainConstipation

Selected guidance · source check 2026-09-07. These 1 source links support selected teaching points, not a complete review of this topic. Check population, setting and local protocol before applying a recommendation.

  • Rosen’s Emergency Medicine, 10th ed. (2023) — back pain
  • ACP guideline (Annals 2017); NICE NG59 (low back pain)
  • NICE NG234 (2023) metastatic spinal cord compression
  • Chou et al., JAMA 2023 systematic review
← Urinary Symptoms & Acute RetentionAirway Symptoms & Stridor →