Back Pain 🦴
On-call guide to acute back pain: red flags, cauda equina (HSE SPRINT), examination, imaging, analgesia, and when to escalate for Irish NCHDs.
📞 What to Ask / Orders to Make
- Current vitals and NEWS: fever, tachycardia, hypotension?
- Pain onset (sudden vs gradual), location, radiation to legs, and severity.
- New bilateral leg symptoms, saddle/perineal numbness, bladder or bowel change, or new weakness?
- Trauma, known cancer, IV drug use, immunosuppression, or recent spinal procedure?
- Ask nurse for bladder scan / post-void residual (PVR) if CES possible, and keep NBM if urgent MRI/transfer likely.
- Review chart: steroids, anticoagulants, recent falls, prior back surgery.
🧾 History
- Onset, duration, character, and aggravating / relieving factors (rest, movement, night pain).
- Radiation: unilateral vs bilateral sciatica; dermatomal pattern; claudication (neurogenic vs vascular).
- Neurological: weakness, numbness, gait change, falls, saddle anaesthesia, sexual dysfunction.
- Sphincter: hesitancy, retention, overflow, new urinary or faecal incontinence, loss of bladder filling / rectal fullness sensation.
- Systemic: fever, weight loss, night sweats, IVDU, recent infection, known malignancy.
- Trauma or osteoporosis risk (age, steroids, previous fracture).
- Past spinal surgery, AAA, pancreatitis, renal colic, or IHD (visceral mimics).
🩺 Examination
- ABC and general: septic, shocked, or in severe distress? Pain posture.
- Vitals: HR, BP (both arms if tearing interscapular pain), RR, SpO₂, temp.
- Spine: midline vs paraspinal tenderness, deformity, step, bruising, surgical scars.
- Lower limbs: power (MRC), tone, reflexes, sensation (dermatomes), straight-leg raise if appropriate.
- Gait if safe. Document clearly and time-stamp findings.
- Perineal / saddle sensation. PR for anal tone and sensation if CES suspected (consent, chaperone). See Digital Rectal Examination.
- Bladder: palpable bladder, PVR on bladder scan. Per HSE CES guideline, PVR >200 mL raises concern but do not use PVR alone.
- Abdomen and pulses if AAA, renal colic, or pancreatitis possible. Chest if thoracic pain or dissection concern.
🚨 Cauda equina: SPRINT (HSE)
- Use the HSE National Clinical Guideline for Cauda Equina Syndrome and local SPRINT for Spine proforma where available.
- S: Saddle paraesthesia / impaired perianal or perineal sensation.
- P: New-onset bilateral radicular pain / bilateral leg symptoms with new neurology.
- R: Retention (including painless retention) or loss of bladder filling / micturition sensation.
- I: New urinary or faecal incontinence.
- N: New motor findings.
- T: Time for MRI. Gold-standard diagnosis is MRI plus clinical assessment; arrange urgently if red flags present.
- Any SPRINT red flag: senior review, document onset times, complete ASIA chart if used locally, PVR, keep fasting, and request urgent MRI via a senior decision-maker per local pathway.
- Inform local orthopaedics early so the spinal pathway can be activated. Pre-op work-up can run in parallel but must not delay MRI.
- MRI access varies by site. Follow local protocol for out-of-hours imaging and transfer; do not delay escalation while negotiating logistics.
🚩 Other red flags / escalate
- Suspected cord compression (progressive bilateral weakness, sensory level, hyperreflexia): urgent senior, MRI, oncology/spine pathway as indicated.
- Infection: fever, IVDU, immunosuppression, recent spinal injection or bacteraemia. Consider discitis / epidural abscess.
- Malignancy: known cancer, unexplained weight loss, constant night pain, thoracic pain in older patients.
- Fracture: significant trauma, osteoporosis, long-term steroids, point tenderness after fall.
- Vascular: sudden tearing back/chest pain, pulse deficit, syncope (dissection / AAA). Treat as emergency.
- Haemodynamic instability, sepsis, or rapidly progressive neurology: ABC, senior, do not attribute to “simple MSK” without a documented exam.
🔍 Differential
- Mechanical / nonspecific low back pain: common; usually no red flags; improve with activity and simple analgesia (NICE NG59).
- Radiculopathy / sciatica: unilateral leg pain ± dermatomal sensory change; most improve without urgent imaging if no CES features.
- Spinal stenosis: neurogenic claudication, relief with flexion.
- Serious spinal pathology: CES, cord compression, infection, malignancy, fracture.
- Referred / visceral: AAA, pancreatitis, pyelonephritis / ureteric colic, peptic disease, ACS / dissection, herpes zoster.
Bilateral sciatica + sphincter / saddle change
- Think of
- Cauda equina until proven otherwise
Fever + back pain + risk factors
- Think of
- Discitis / epidural abscess
Cancer history + night / thoracic pain
- Think of
- Metastases / cord compression
Trauma / osteoporosis + point tenderness
- Think of
- Vertebral fracture
Tearing interscapular / flank pain + shock
- Think of
- Dissection / AAA
Unilateral sciatica, no red flags
- Think of
- Radiculopathy; safety-net and analgesia
| Pattern | Think of |
|---|---|
| Bilateral sciatica + sphincter / saddle change | Cauda equina until proven otherwise |
| Fever + back pain + risk factors | Discitis / epidural abscess |
| Cancer history + night / thoracic pain | Metastases / cord compression |
| Trauma / osteoporosis + point tenderness | Vertebral fracture |
| Tearing interscapular / flank pain + shock | Dissection / AAA |
| Unilateral sciatica, no red flags | Radiculopathy; safety-net and analgesia |
🧪 Investigations
- Directed by red flags, not routine for simple mechanical pain.
- Bloods if unwell or infection/malignancy concern: FBC, U&E, CRP, ± cultures, LFTs, bone profile.
- Bladder scan / PVR if CES possible. Catheterise for retention after senior discussion and document volumes.
- Urinalysis if flank pain or UTI suspected.
- ECG if chest/interscapular pain or cardiac mimic possible.
- X-ray: trauma / suspected osteoporotic fracture; limited value for CES or soft-tissue infection.
- MRI spine: urgent for CES, cord compression, or suspected spinal infection per senior/radiology. Phone radiology for emergency slots (see Requesting Radiology).
- CT aorta / CT AP if dissection, AAA, or visceral emergency suspected instead of MSK back pain.
💊 Initial management
- Red-flag pathway first. Do not let analgesia delay urgent MRI or senior review when CES is possible.
- Analgesia: paracetamol ± NSAID if no contraindication (AKI, ulcer, anticoagulation, heart failure). Escalate opioids carefully; prescribe laxatives with opioids. See Analgesia.
- Avoid prolonged bed rest for nonspecific low back pain; encourage mobilisation as pain allows (NICE NG59).
- Neuropathic agents (e.g. amitriptyline) may help radicular pain once serious pathology excluded; follow local formulary.
- If discharging or not imaging urgently: safety-net for SPRINT symptoms (saddle change, retention, incontinence, new bilateral weakness). Give clear return advice.
- Document neuro exam, PVR, consent for PR, working diagnosis, and escalation conversations.
Related NICE guidance
NICENICE NG59 — Low back pain and sciatica in over 16s: assessment and management (updated Dec 2020)
Full guidance on nice.org.uk. BetterCall is not endorsed by NICE.
Note Template
Ready-to-use clinical note structure
🕒 29 / 10 / 2026 — 22:58 ATRP re: back pain Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [cancer, osteoporosis, IVDU, spinal surgery, AAA] 🧾 Hx: • Onset, duration, character, night pain • Radiation: [unilateral / bilateral sciatica] • SPRINT screen: saddle paraesthesia, bilateral radicular pain, retention, incontinence, new motor findings • Systemic: [fever, weight loss, trauma, immunosuppression] • Bladder / bowel: [normal / hesitancy / retention / incontinence] 🩺 Exam: • Vitals: HR __ BP __ Temp __ RR __ SpO₂ __ • Spine tenderness: [midline / paraspinal / level] • Lower limbs: power (MRC), sensation, reflexes, gait • Saddle / perineal sensation: [intact / reduced / absent] • PR (if indicated): anal tone / sensation [ ]; consent and chaperone documented • PVR / bladder scan: __ mL (concern if >200 mL per HSE CES guideline; not used alone) • Abdomen / pulses if visceral concern: [ ] 📋 Impression: Likely: [mechanical / radiculopathy / ?CES / infection / malignancy / fracture / referred visceral] SPRINT red flags: [Y/N — list] 📌 Plan: • [Senior review / urgent MRI / orthopaedics–spine pathway if CES red flags] • Keep NBM if urgent MRI / transfer likely • Analgesia; avoid prolonged bed rest if nonspecific mechanical pain • Safety-net advice if not imaging urgently • Document onset times and escalation conversations 👤 [Your Name], [Role] IMC: _______
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