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symptom.back_pain.ed.v1PRODUCTION
symptom.back_pain.ed.v1

Acute back pain (ED red-flag workup)

symptomacuteundifferentiatedadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Pain onset, location, quality; SNNOOP10 red-flag screen anchored (ACP 2017 PMID 28192789; Stochkendahl PMID 33558739)

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Advance rule
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Advance when

pain characterized + red-flag screen run

Patient inputs (32)

Age >50 with new back pain raises red-flag prior (malignancy, fracture, AAA, dissection) (ACP 2017 PMID 28192789)

Pregnancy raises differential (preeclampsia, abruption, MSK from biomechanics); reproductive-age females need β-hCG before imaging

Hypotension flags AAA leak / dissection / urosepsis (Sakalihasan 2018; SSC 2026)

Tachycardia in volume loss / dissection / sepsis

Fever raises infection prior (SEA / osteomyelitis / pyelonephritis) (Berbari IDSA 2015 PMID 28118470)

Known malignancy (breast, lung, prostate, renal, multiple myeloma, lymphoma) — new back pain warrants STAT MRI for metastatic cord compression

IVDU / immunosuppression / diabetes / chronic steroid / dialysis / recent spinal procedure → SEA prior (Bond 2016 PMID 28121397)

Osteoporosis or chronic glucocorticoid use → fragility vertebral fracture prior (Genant PMID 20308793)

High-energy trauma → unstable fracture risk; low-energy in osteoporosis → compression fracture

Smoking + HTN + male + >65 + family history → AAA / dissection (Sakalihasan 2018 PMID 23335416)

Anticoagulation raises spontaneous epidural hematoma prior (rare but mimics SEA / cauda equina)

Pregnancy → preeclampsia / HELLP; postpartum → cortical vein thrombosis with referred back pain

Sciatica (L4-S1 dermatome) = radiculopathy; anterior thigh = L2-L4; chest = thoracic dissection; groin = AAA or urolithiasis (ACP 2017)

Saddle anesthesia (S2-S4) is the most specific feature of cauda equina syndrome — STAT MRI threshold (Kuris 2015 PMID 26416327)

New urinary retention / fecal incontinence / overflow urinary incontinence — late but specific cauda equina feature (Kuris 2015)

Bilateral lower extremity weakness or paresthesia raises cauda equina prior dramatically (Kuris 2015)

Persistent fever + back pain + IVDU or immunocompromise → spinal epidural abscess (Bond 2016 PMID 28121397; Berbari IDSA 2015 PMID 28118470)

Night pain or pain at rest unrelieved by position raises malignancy / infection prior (ACP 2017)

Progressive motor weakness / progressive sensory loss / progressive bowel-bladder symptoms is RED-FLAG (Kuris 2015; ACP 2017)

Sudden maximal-intensity onset = AAA / dissection / acute fracture; gradual = inflammatory / mechanical (Sakalihasan 2018; ACP 2017)

Cervical / thoracic / lumbar; midline vs paraspinal vs flank — anchors differential (mechanical vs visceral vs aortic) (ACP 2017)

Tearing = dissection / AAA; constant + worse at night = malignancy / infection; mechanical worse with movement / better with rest = MSK (ACP 2017; Berbari IDSA PMID 28118470)

Leukocytosis in SEA / osteomyelitis / pyelonephritis; anemia in malignancy or bleeding (Bond 2016)

ESR + CRP screening for SEA / osteomyelitis — CRP >50 or ESR >50 raises suspicion; high NPV when both normal (Berbari IDSA 2015 PMID 28118470; Bond 2016)

UA for hematuria (urolithiasis) / pyuria + nitrites (pyelonephritis); β-hCG if reproductive-age female

eGFR for contrast decisions (CTA / MRI gad) and dosing

Plain films are LOW-yield for soft tissue / SEA / cauda equina but useful for compression fracture screen (ACP 2017)

GOLD STANDARD for cauda equina / SEA / osteomyelitis / metastatic compression — STAT, gadolinium-enhanced (Kuris 2015; Bond 2016; Berbari IDSA 2015)

CTA chest for thoracic dissection (AHA 2022); CTA abdomen for AAA (Sakalihasan PMID 23335416)

CT KUB for urolithiasis (flank pain + hematuria)

>20 mmHg differential between arms suggests thoracic aortic dissection (AHA 2022)

Blood cultures × 2 BEFORE antibiotics for SEA / osteomyelitis / urosepsis (Berbari IDSA 2015)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (12)

12 need judgement
  • informationallife_threateningcauda_equina_syndrome
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningspinal_epidural_abscess
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmetastatic_cord_compression
    Known cancer (breast, lung, prostate, renal, multiple myeloma, lymphoma) + new back pain + neuro deficit or night pain — STAT MRI + dexamethasone + oncology + RT/neurosurgery
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningaaa_leak_with_back_pain
    Hypotension + flank/midline back or abdominal pain + age >65 + male smoker + vascular risk + pulsatile mass (poor sensitivity) — STAT CTA aorta (Sakalihasan PMID 23335416)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningthoracic_aortic_dissection_back
    Tearing thoracic back / interscapular pain + BP differential between arms >20 mmHg + HTN/Marfan/bicuspid AV/prior dissection — STAT CTA chest (AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningspontaneous_epidural_hematoma
    Anticoagulation + abrupt severe back pain + neuro deficit — STAT MRI gad + reversal + neurosurgery
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverevertebral_osteomyelitis
    Insidious progressive back pain + fever + elevated ESR/CRP + IVDU/dialysis/diabetes/immunocompromise — MRI gad + biopsy + IDSA antibiotics (Berbari IDSA 2015 PMID 28118470)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepyelonephritis_urosepsis
    Flank pain + dysuria + fever + pyuria/nitrites on UA + sepsis features (qSOFA ≥2 OR lactate >2) — IDSA UTI + SSC 2026 sepsis bundle
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereprogressive_neuro_deficit
    Progressive motor weakness OR progressive sensory loss OR progressive bowel/bladder symptoms over hours to days — STAT MRI + neurosurgery consult (Kuris 2015; Bond 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatevertebral_compression_fracture
    Osteoporosis OR chronic glucocorticoid use + minor trauma + acute focal back pain + thoracolumbar tenderness — XR/MRI; Genant grading I-III (PMID 20308793)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterenal_colic_urolithiasis
    Colicky flank pain radiating to groin + hematuria + cannot find comfortable position + age 30-50 — CT KUB non-contrast (uro.urolithiasis.v1 routing)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildmechanical_back_pain_no_red_flag
    Acute low back pain without any SNNOOP10 red flag + benign exam + functional — discharge with conservative care + PCP follow-up 1-2 weeks (ACP 2017 PMID 28192789; USPSTF PMID 29457591; Stochkendahl PMID 33558739)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

ed playbook — drug actions (7)

  1. 1. acetaminophen
    rxcui 161
    650-1000 mg PO/IV • PO or IV • q4-6h max 4 g/day
    trigger: Mild-moderate back pain without red flags
    ACP 2017 PMID 28192789 — acetaminophen first-line for acute back pain
  2. 2. ibuprofen OR naproxen
    rxcui 5640
    Ibuprofen 400-600 mg PO q6h OR naproxen 500 mg PO BID • PO • short course (≤7-14 d)
    trigger: Moderate pain inadequate with acetaminophen alone; no renal/GI/bleeding contraindication
    ACP 2017 — NSAIDs are first-line pharmacotherapy for acute low back pain
  3. 3. cyclobenzaprine
    rxcui 21949
    5-10 mg PO TID • PO • q8h × 3-7 d
    trigger: Muscle spasm component
    ACP 2017 — skeletal muscle relaxants for short-term acute use only; sedation in elderly per AGS Beers
  4. 4. morphine OR oxycodone
    Morphine 4-8 mg IV q15-30 min PRN OR oxycodone 5-10 mg PO q6h • IV or PO • short course only
    trigger: Severe acute pain refractory to non-opioid OR functional impairment (NRS ≥7) + appropriate risk-benefit
    ACP 2017 + USPSTF 2018 — opioids only for severe acute pain refractory to non-opioid; lowest effective dose × shortest duration
  5. 5. vancomycin + ceftriaxone OR cefepime
    Vanc 15-20 mg/kg IV (loading) + ceftriaxone 2 g IV daily OR cefepime 2 g IV q8h • IV • AFTER blood cultures
    trigger: Confirmed or strongly suspected spinal epidural abscess or vertebral osteomyelitis on MRI
    IDSA 2015 PMID 28118470 — empiric vanc + 3rd/4th gen cephalosporin pending culture; tailor to organism; 6-8 weeks IV typically
  6. 6. dexamethasone
    rxcui 3264
    10 mg IV loading then 4 mg IV q6h • IV • until MRI + RT plan
    trigger: Suspected metastatic cord compression (known cancer + new back pain + neuro deficit)
    Reduces cord edema bridging to definitive RT/surgery; route to oncology + radiation oncology + spine surgery
  7. 7. esmolol or labetalol
    Esmolol 500 mcg/kg bolus then 50 mcg/kg/min; labetalol 10-20 mg IV • IV • titrate HR <60 + SBP <120
    trigger: Suspected thoracic aortic dissection (tearing thoracic back pain + BP differential)
    AHA 2022 Acute Aortic Disease — impulse control FIRST before vasodilator; route to cardio.aortic-dissection.core.v1

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Acute back pain (low / thoracic / cervical) — drives red-flag screen first (ACP Qaseem 2017 PMID 28192789); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute back pain (ED red-flag workup)** (symptom.back_pain.ed.v1).
Phenotype framing: Mechanical/MSK (>85%) / sciatica + radiculopathy (~10-15%) / cauda equina (~1/1000-5000 in ED back pain) / spinal epidural abscess (~0.2-1.2/10000) / vertebral osteomyelitis / metastatic compression (~5% of cancer patients) / vertebral fracture (osteoporotic) / AAA leak (~0.1% of ED back pain) / aortic dissection (~0.3%) / pyelonephritis / renal colic / spinal stenosis (chronic — neurogenic claudication) / ankylosing spondylitis / fibromyalgia (chronic; exclusion) (ACP 2017 PMID 28192789; Stochkendahl 2018 PMID 33558739)
Scope: Pain onset, location, quality; SNNOOP10 red-flag screen anchored (ACP 2017 PMID 28192789; Stochkendahl PMID 33558739)

No severity triggers fired against current inputs.

Plan

No regimen axis selected (engine has no regimen_axes or could not match).

Setting playbook (ed) — Red-flag rule-out — do NOT miss cauda equina syndrome, spinal epidural abscess, vertebral osteomyelitis, metastatic cord compression, vertebral fracture, AAA leak, thoracic dissection, urosepsis. Mechanical/MSK back pain (>85%) is a diagnosis of exclusion after SNNOOP10 screen + targeted imaging if any flag positive. ACP 2017 + USPSTF 2018 + Stochkendahl 2018 guideline implementation.
1. acetaminophen 650-1000 mg PO/IV PO or IV q4-6h max 4 g/day — Mild-moderate back pain without red flags (ACP 2017 PMID 28192789 — acetaminophen first-line for acute back pain)
2. ibuprofen OR naproxen Ibuprofen 400-600 mg PO q6h OR naproxen 500 mg PO BID PO short course (≤7-14 d) — Moderate pain inadequate with acetaminophen alone; no renal/GI/bleeding contraindication (ACP 2017 — NSAIDs are first-line pharmacotherapy for acute low back pain)
3. cyclobenzaprine 5-10 mg PO TID PO q8h × 3-7 d — Muscle spasm component (ACP 2017 — skeletal muscle relaxants for short-term acute use only; sedation in elderly per AGS Beers)
4. morphine OR oxycodone Morphine 4-8 mg IV q15-30 min PRN OR oxycodone 5-10 mg PO q6h IV or PO short course only — Severe acute pain refractory to non-opioid OR functional impairment (NRS ≥7) + appropriate risk-benefit (ACP 2017 + USPSTF 2018 — opioids only for severe acute pain refractory to non-opioid; lowest effective dose × shortest duration)
5. vancomycin + ceftriaxone OR cefepime Vanc 15-20 mg/kg IV (loading) + ceftriaxone 2 g IV daily OR cefepime 2 g IV q8h IV AFTER blood cultures — Confirmed or strongly suspected spinal epidural abscess or vertebral osteomyelitis on MRI (IDSA 2015 PMID 28118470 — empiric vanc + 3rd/4th gen cephalosporin pending culture; tailor to organism; 6-8 weeks IV typically)
6. dexamethasone 10 mg IV loading then 4 mg IV q6h IV until MRI + RT plan — Suspected metastatic cord compression (known cancer + new back pain + neuro deficit) (Reduces cord edema bridging to definitive RT/surgery; route to oncology + radiation oncology + spine surgery)
7. esmolol or labetalol Esmolol 500 mcg/kg bolus then 50 mcg/kg/min; labetalol 10-20 mg IV IV titrate HR <60 + SBP <120 — Suspected thoracic aortic dissection (tearing thoracic back pain + BP differential) (AHA 2022 Acute Aortic Disease — impulse control FIRST before vasodilator; route to cardio.aortic-dissection.core.v1)

Non-pharmacologic actions:
- Two IVs if hemodynamically unstable or imaging planned
- Foley catheter for post-void residual + monitoring if cauda equina suspected
- STAT MRI lumbar spine (or relevant level) WITH gadolinium if cauda equina / SEA / osteomyelitis / metastatic compression suspected — do NOT delay for trial of conservative therapy
- Neurosurgery / spine surgery consult STAT for cauda equina (decompression goal <24-48 h) OR SEA with neuro deficit
- Oncology + radiation oncology consult for confirmed metastatic cord compression (steroid bridge → RT or decompressive surgery per SCORS criteria)
- Vascular surgery consult for confirmed AAA leak or thoracic dissection
- Urology consult for complicated urolithiasis (obstruction + infection)
- Avoid bed rest >2 days for mechanical back pain (ACP 2017)
- PT referral for subacute / chronic mechanical back pain (USPSTF 2018; Stochkendahl 2018)

Monitoring

Setting (ed) monitoring:
- Vital signs q30 min × 2 h then per disposition
- Continuous SpO2 and telemetry if dissection or AAA suspicion
- Neuro exam q4-6h on observation — motor, sensory (saddle), reflexes, rectal tone, PVR
- Pain reassessment 30 min post analgesia
- Repeat ESR + CRP trending for confirmed SEA/osteomyelitis (Berbari IDSA 2015)

Follow-up plan: 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
- Close-out criterion: discharge bundle prescribed + follow-up scheduled

Monitoring phase: Serial neuro exam q4-6h on observation; pain reassessment; recheck red flags if symptom evolution; serial ESR/CRP trending for confirmed SEA/osteo (Berbari IDSA 2015)

Disposition

Current setting: ed — Red-flag rule-out — do NOT miss cauda equina syndrome, spinal epidural abscess, vertebral osteomyelitis, metastatic cord compression, vertebral fracture, AAA leak, thoracic dissection, urosepsis. Mechanical/MSK back pain (>85%) is a diagnosis of exclusion after SNNOOP10 screen + targeted imaging if any flag positive. ACP 2017 + USPSTF 2018 + Stochkendahl 2018 guideline implementation.

Disposition criteria:
- Discharge: mechanical/MSK back pain WITHOUT red flags + functional + reliable PCP follow-up 1-2 weeks + return precautions documented (ACP 2017; USPSTF 2018)
- Observation: equivocal MRI / awaiting ESR-CRP trend / cauda equina rule-out pending after PVR + neuro exam
- Admit: confirmed SEA, osteomyelitis, metastatic compression, complicated pyelonephritis, vertebral fracture with neuro deficit, severe pain with functional impairment, social inability to manage at home
- OR direct: cauda equina syndrome (decompression goal <24-48 h); SEA with progressive neuro deficit; unstable vertebral fracture with neuro deficit; AAA leak; aortic dissection Stanford A
- ICU: hemodynamic instability; AAA / dissection awaiting OR; septic shock from urosepsis

Escalation triggers (move to higher acuity):
- New or progressive saddle anesthesia + bowel/bladder + bilateral leg weakness → STAT MRI + neurosurgery within 24-48 h (Kuris 2015 PMID 26416327)
- Fever + IVDU/immunocompromise + new back pain + elevated CRP/ESR → STAT MRI gad + IDSA empiric antibiotics + neurosurgery (Bond 2016 PMID 28121397)
- Known cancer + new back pain + neuro deficit or night pain → STAT MRI + dexamethasone + oncology + RT/neurosurgery
- Hypotension + flank/midline back pain + age >65 → STAT CTA aorta → vasc.aaa.v1 + vascular surgery
- Tearing thoracic back pain + BP differential → STAT CTA chest → cardio.aortic-dissection.core.v1 + vascular/CT surgery
- Pyelonephritis + sepsis criteria → id.sepsis.core.v1 + admission
- Pediatric back pain — separate workup (less common; higher relative malignancy/infection prior); not in this engine scope

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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] Known cancer (breast, lung, prostate, renal, multiple myeloma, lymphoma) + new back pain + neuro deficit or night pain — STAT MRI + dexamethasone + oncology + RT/neurosurgery

Citations

- 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 [PMID:28192789](https://pubmed.ncbi.nlm.nih.gov/28192789/)
- Cited evidence (PMID 10584107) [PMID:10584107](https://pubmed.ncbi.nlm.nih.gov/10584107/)

Last reconciled with current guidelines: 2026-05-30.
References
  • 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 — PMID:28192789
  • Cited evidence (PMID 10584107) — PMID:10584107