Critical Alerts

• Cauda equina syndrome is a surgical emergency: Saddle anesthesia, urinary retention, bilateral weakness
• Red flags require urgent evaluation: Cancer, infection, fracture, neurological deficit
• Most low back pain is benign and self-limited: 90% resolve within 6 weeks
• Imaging rarely changes management initially: Reserve for red flags
• Early mobilization improves outcomes: Avoid prolonged bed rest
• Opioids should be avoided or used short-term only

Red Flags (TUNA FISH)

Cauda Equina Syndrome Warning Signs

Emergency Treatments

Overview

Acute low back pain (LBP) is pain in the lumbosacral region lasting less than 4 weeks. It is one of the most common reasons for ED visits and physician consultation. The key ED task is identifying the rare serious causes (cauda equina, cancer, infection, fracture) while appropriately managing the majority with reassurance, analgesia, and activity.

Classification

By Duration:

By Cause:

Epidemiology

• Lifetime prevalence: 70-80%
• Leading cause of disability worldwide
• Peak age: 30-50 years
• Recurrence common: ~25-50%

Etiology

Mechanical/Non-Specific (~85%):

Radiculopathy/Sciatica (~5-10%):

Serious Pathology (<5%):

(Integrated into Clinical Presentation above)

Red Flags

Must Exclude Serious Pathology

Imaging Guidelines

Imaging NOT Indicated for Most Acute LBP:

• No red flags = No imaging initially
• Most acute LBP resolves in 4-6 weeks

When to Image:

Laboratory Studies

Condition Explanation

• "Low back pain is very common and usually not serious."
• "Most cases improve within a few weeks with activity and medication."
• "Staying active is better than bed rest."

Home Care

• Use NSAIDs as directed
• Apply ice or heat for comfort
• Stay active; gentle walking and stretching
• Avoid lifting heavy objects
• Maintain good posture

Warning Signs to Return

• Numbness in groin or inner thighs (saddle area)
• Difficulty urinating or loss of bowel control
• Weakness in legs or feet getting worse
• Fever or chills
• Unexplained weight loss

Special Populations

Elderly

• Higher risk of serious pathology (cancer, fracture)
• Lower threshold for imaging
• More cautious with NSAIDs (renal, GI, CV risk)

Cancer History

• Any new LBP is metastatic disease until proven otherwise
• MRI of entire spine

Osteoporosis/Steroid Use

• Vertebral compression fractures
• X-ray initially; MRI if neurological symptoms

Pregnancy

• Avoid NSAIDs (especially 3rd trimester)
• Acetaminophen for analgesia
• Physical therapy helpful

Performance Indicators

Documentation Requirements

• Red flag assessment
• Neurological exam (strength, reflexes, sensation)
• Rectal tone and saddle sensation (if cauda equina suspected)
• Imaging rationale (if performed)
• Discharge instructions

Key Clinical Pearls

Diagnostic Pearls

• Cauda equina = Emergent MRI: Don't miss bladder/bowel symptoms
• Red flags guide imaging: Most acute LBP doesn't need imaging
• SLR is sensitive for radiculopathy: Crossed SLR is more specific
• Check perianal sensation and rectal tone: For cauda equina
• Age >50 + new LBP: Consider malignancy/fracture
• IVDU + back pain + fever = Epidural abscess: MRI urgently

Treatment Pearls

• NSAIDs are first-line: Better than acetaminophen alone
• Muscle relaxants are adjuncts: Short-term only; sedating
• Avoid opioids: No long-term benefit; addiction risk
• Early activity is key: Bed rest worsens outcomes
• Steroids only for radiculopathy: Not for mechanical LBP
• PT referral for subacute/chronic: Core strengthening

Disposition Pearls

• Most can be discharged: With reassurance and analgesia
• Admit for red flags: Cauda equina, abscess, cancer
• Follow-up in 1-2 weeks: If not improving
• Specialist for radiculopathy not improving: 4-6 weeks