Back Pain 🦴

• 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.

• 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).

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

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