Back Pain

at the bedside

airway, breathing, circulation; full vitals; IV access if unwell or the pain was abrupt
ask the screen → bladder, bowel, saddle numbness, leg weakness, sexual change, new difficulty walking: on every patient
chart review → recent bacteremia or line infection, infection elsewhere, known cancer, anticoagulant, recent spinal or epidural procedure
pulses and BP both arms → abrupt tearing pain: consider acute aortic syndrome urgently
temperature → fever with spinal tenderness is infection until proven otherwise

escalate now if

new bladder, bowel, saddle or sexual symptoms, bilateral leg weakness or new difficulty walking → cauda equina, MRI and the spinal team in parallel
abrupt tearing pain, syncope, hypotension, pulse or BP difference → dissection or leaking AAA, never muscular
known cancer with new back pain plus any neurological symptom or sign → cord compression, dexamethasone and MRI
fever, recent bacteremia, IV drug use, immunosuppression, recent spinal procedure → spinal infection
epigastric pain to the back with vomiting, flank pain with fever, or anticoagulated with a falling hemoglobin → referred pain

must not miss

cauda equina → retention or incontinence, saddle numbness, bilateral sciatica or weakness, new gait disturbance
aortic dissection or AAA → abrupt, severe from the start, tearing, migrating; pulse deficit, hypotension; older, hypertensive, smoker, connective tissue disease
cord compression → cancer, night pain, sensory level, hyperreflexia, new weakness or difficulty walking
spinal infection (discitis, vertebral osteomyelitis, epidural abscess) → fever, focal tenderness, recent bacteremia or line infection, IV drug use, diabetes, recent procedure
fracture → fall on the ward, osteoporosis, chronic steroids, point tenderness

referred

pancreatitis → epigastric to back, vomiting, alcohol or gallstones → abdominal pain
pyelonephritis, stones → flank pain, fever, dysuria, hematuria → dysuria
retroperitoneal bleed → anticoagulated, falling hemoglobin, flank bruising

common

mechanical back pain → worse with movement, no red flags, normal neurology; sciatica down one leg

pain → onset (sudden vs gradual), new since admission or worse than baseline, site, radiation to legs, night or rest pain, tearing character
ask → bladder, bowel, saddle sensation, sexual function, walking; ask directly, patients rarely volunteer it
history → cancer, fever, weight loss, IV drug use, immunosuppression, osteoporosis, steroids, known aneurysm, anticoagulant, recent bacteremia, lines or procedures
examine → BP both arms, peripheral pulses, pulsatile mass; spinal tenderness or step; gait if safe; tone, power, reflexes, sensory level, plantars; perianal sensation when indicated; post-void residual as an adjunct

cauda equina: what counts

any new or worsening symptom in the last 2 weeks
difficulty starting the stream, or loss of the sensation of passing urine
altered perianal, perineal or genital sensation, reported or tested
loss of the sensation of rectal fullness; new erectile or ejaculatory failure
severe or progressive bilateral leg weakness, or new difficulty walking
painless retention with overflow is late; waiting for it is waiting too long
a rectal exam is not needed to request MRI; anal tone is a late sign; a normal post-void residual does not exclude it; a residual ≥ 200 mL makes it more likely

MRI lumbosacral spine → cauda equina suspected: emergency, requested now while the spinal team is called, not after
MRI extent → whole spine when cord compression is suspected (multilevel disease is common) or infection may be multifocal; otherwise by presentation
CT angiography aorta → aortic syndrome suspected, once stable enough
two blood culture sets, CBC, ESR and CRP → fever or infection risk; Brucella serology if subacute or an exposure history; cultures before antibiotics unless septic
lipase, LFT, urinalysis → referred causes
fracture imaging → plain films miss occult fractures; CT or MRI by mechanism, osteoporosis and neurology; a normal film excludes none of the emergencies above

cauda equina

emergency MRI now and spinal surgery or neurosurgery at the same time, per the local pathway; do not wait for one to start the other; no safe 24 or 48 h window; document symptom, request and call times
NPO for possible surgery; catheter if retained → urinary retention

aortic dissection or ruptured AAA

cardiothoracic or vascular surgery and ICU now; large-bore access, crossmatch, IV opioid; no antiplatelet or anticoagulant until dissection is excluded
dissection, perfusing and not hypotensive → β-blocker first, goals HR < 60 and SBP 100–120 mmHg, vasodilator only after rate control; not goals for the hypotensive or a suspected rupture; full dosing → chest pain
ruptured or leaking AAA → permissive hypotension while surgery is arranged; do not over-resuscitate

malignant cord compression

suspected MSCC, cancer plus neurological symptoms or signs → dexamethasone 16 mg/day IV/PO (as 8 mg BD) now, MRI within 24 h and sooner if the deficit is progressing, oncology and spinal surgery tonight; lie flat if the spine may be unstable
with the steroid → check glucose; PPI only with an NSAID or GI risk factors, not routinely → steroids
lymphoma or myeloma possible, no neurology → oncology or hematology advice before any steroid
spinal metastases suspected, neurology normal → no steroid tonight; MRI within a week via the treating team and oncology; re-examine each shift

spinal infection

stable, neurologically intact → two blood culture sets, ESR and CRP, urgent MRI, spinal surgery and ID tonight; no antibiotics until sampling (cultures, image-guided biopsy)
septic, unstable or deteriorating → cultures if no delay, then vancomycin 25 mg/kg IV load, then by weight, renal function and levels, + ceftriaxone 2 g IV q24h; ICU if shocked; spinal surgery or neurosurgery now for epidural abscess or any deficit → empiric antibiotics

referred pain

pancreatitis → abdominal pain; pyelonephritis or infected stone → dysuria; retroperitoneal bleed → CT, hold anticoagulant → hemoglobin drop

mechanical back pain, no red flags

no routine imaging for uncomplicated mechanical pain; mobilize, superficial heat; bed rest makes it worse
NSAID first line → if kidneys, stomach and heart allow: ibuprofen 400 mg PO TDS, lowest dose for the shortest time → analgesia
do not offer paracetamol alone for nonspecific low back pain; opioids are not routine
short-term option, selected patients → orphenadrine-paracetamol (Muscadol): anticholinergic, avoid in the elderly, glaucoma, prostatic enlargement; count its paracetamol toward the daily total
avoid routinely → gabapentinoids and oral corticosteroids for sciatica
reassess in 30–60 min and in the morning; the treating team plans follow-up

hand over → red-flag screen result, analgesia given, imaging ordered and time, teams called, escalation trigger

source	type
GIRFT national suspected cauda equina pathway and 2026 review (BASS and SBNS); no North American equivalent	specialty-society guidance
2022 ACC/AHA aortic disease guideline	international guideline
ACP 2017 low back pain guideline	specialty-society guidance
NICE NG59 low back pain and sciatica	national guideline
NICE NG234 metastatic spinal cord compression	national guideline
IDSA 2015 native vertebral osteomyelitis guideline	international guideline

Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.

free the on-call checklist covers the whole shift on one printable page.

studying for the IM exam? the IM Rapid Review covers this in the same format. see the sample chapter.

reviewed Jul 2026updated Oct 2026file complaint/back-pain