Patient handout

Acute back pain (ED red-flag workup)

PRODUCTION

1. Your condition

This handout is for acute back pain (ed red-flag workup). Your care team identified this based on: acute back pain (low / thoracic / cervical) — drives red-flag screen first (acp qaseem 2017 pmid 28192789).

Other reasons your team may use this plan: back pain with sciatica or radiculopathy — assess motor/sensory deficit per dermatome (acp 2017); back pain + motor weakness or saddle anesthesia or bowel/bladder dysfunction → suspect cauda equina — stat mri (kuris 2015 pmid 26416327); back pain + fever + ivdu or immunocompromise → suspect spinal epidural abscess — stat mri gad (bond 2016 pmid 28121397).

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Saddle anesthesia (S2-S4) + new bowel/bladder dysfunction + bilateral leg weakness OR PVR >200 mL — STAT MRI lumbar gadolinium + neurosurgery consult (Kuris 2015 PMID 26416327)(life-threatening)
Fever + IVDU OR immunocompromise OR recent spinal procedure + new back pain + elevated CRP/ESR — STAT MRI gad + neurosurgery (Bond 2016 PMID 28121397; Berbari IDSA PMID 28118470)(life-threatening)
Insidious progressive back pain + fever + elevated ESR/CRP + IVDU/dialysis/diabetes/immunocompromise — MRI gad + biopsy + IDSA antibiotics (Berbari IDSA 2015 PMID 28118470)
Known cancer (breast, lung, prostate, renal, multiple myeloma, lymphoma) + new back pain + neuro deficit or night pain — STAT MRI + dexamethasone + oncology + RT/neurosurgery(life-threatening)
Hypotension + flank/midline back or abdominal pain + age >65 + male smoker + vascular risk + pulsatile mass (poor sensitivity) — STAT CTA aorta (Sakalihasan PMID 23335416)(life-threatening)
Tearing thoracic back / interscapular pain + BP differential between arms >20 mmHg + HTN/Marfan/bicuspid AV/prior dissection — STAT CTA chest (AHA 2022)(life-threatening)
Flank pain + dysuria + fever + pyuria/nitrites on UA + sepsis features (qSOFA ≥2 OR lactate >2) — IDSA UTI + SSC 2026 sepsis bundle
Progressive motor weakness OR progressive sensory loss OR progressive bowel/bladder symptoms over hours to days — STAT MRI + neurosurgery consult (Kuris 2015; Bond 2016)
Anticoagulation + abrupt severe back pain + neuro deficit — STAT MRI gad + reversal + neurosurgery(life-threatening)

5. Follow-up

Mechanical/MSK discharged: PCP within 1-2 weeks; conservative care (early mobilization, heat, NSAID, PT); avoid bed rest >2 days; return precautions (worsening pain, new neuro deficit, fever, bowel/bladder, weight loss); ACP 2017 + USPSTF 2018 endorse exercise / PT / cognitive-behavioral / spinal manipulation for subacute

6. Sources

Guideline: 2017 ACP Qaseem low back pain guideline + 2018 USPSTF + 2018 Stochkendahl ACP implementation + 2015 IDSA Berbari osteomyelitis + 2016 Bond SEA + 2015 Kuris cauda equina + Genant compression fracture grading + AHA 2022 Acute Aortic Disease + 2018 Sakalihasan AAA