Back Pain 🦴
UK on-call guide to acute back pain: GIRFT suspected cauda equina pathway, emergency vs urgent referral, MRI at the presenting hospital, bladder scan, and when to escalate.
📞 What to Ask / Orders to Make
- Current vitals and NEWS2: fever, tachycardia, hypotension?
- Pain onset (sudden vs gradual), location, radiation to legs, and severity.
- CES symptoms in the last 2 weeks: urinary initiation or flow sensation, saddle / perineal / genital sensation, bilateral leg weakness, rectal fullness, or sexual function?
- Trauma, known cancer, IV drug use, immunosuppression, or recent spinal procedure?
- Ask for a bladder scan if CES is possible. Keep nil by mouth if emergency MRI is likely.
- Review chart: steroids, anticoagulants, recent falls, prior back surgery, MRI implants or metal.
🧾 History
- Onset, duration, character, and aggravating / relieving factors (rest, movement, night pain).
- Radiation: unilateral vs bilateral sciatica; whether unilateral pain has become bilateral; dermatomal pattern; claudication (neurogenic vs vascular).
- Neurological: weakness, numbness, gait change, falls.
- Sphincter and pelvic: hesitancy, impaired flow sensation, retention, incontinence, loss of bladder filling or rectal fullness, sexual dysfunction.
- Saddle / perineal / genital sensory change, including altered feeling when wiping.
- When CES-type symptoms started, and whether they are progressing or have been static for more than 2 weeks.
- 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, NEWS2.
- Spine: midline vs paraspinal tenderness, deformity, step, bruising, surgical scars.
- Lower limbs: power (MRC), tone, reflexes, sensation (dermatomes), including knee extension, ankle eversion, and foot dorsiflexion. Gait if safe. Time-stamp findings.
- Document subjective perianal, perineal, and genital sensation (S2–S5). GIRFT does not require a digital rectal examination for triage; record it if performed (consent, chaperone). See Digital Rectal Examination.
- Bladder: palpable bladder and bladder scan. Do not use residual volume alone to decide on MRI. See CES section for GIRFT scan thresholds.
- Abdomen and pulses if AAA, renal colic, or pancreatitis possible. Chest if thoracic pain or dissection concern.
🚨 Cauda equina: GIRFT pathway
- Use the GIRFT National Suspected CES Pathway and your Trust CES MRI form / SOP. CES is a clinical diagnosis supported by MRI; no single symptom or sign rules it in or out. Negative examination does not exclude CES if the history is concerning.
- Emergency route: back pain and/or sciatica plus any CES feature that started within 2 weeks. Send now to the nearest hospital with emergency MRI. A telephone assessment is enough if a face-to-face review would delay transfer.
- CES features for the emergency route: difficulty starting urine or impaired flow sensation; altered saddle, perineal, or genital sensation; severe or progressive bilateral leg weakness (knee extension, ankle eversion, or foot dorsiflexion); loss of rectal fullness sensation; new sexual dysfunction.
- Urgent route (MSK triage within 2 weeks, not emergency MRI): sudden bilateral sciatica, or unilateral sciatica that has become bilateral, without CES features. Safety-net during the wait. If CES features then appear, switch to the emergency route.
- Static CES-type symptoms for more than 2 weeks also go via the urgent MSK route rather than same-day MRI, unless they are progressing.
- Any emergency-route patient: senior decision-maker (ST4 or equivalent) before requesting MRI, document onset times, bladder scan, keep nil by mouth, and request emergency MRI at the hospital of presentation.
- Do not phone the on-call spinal surgical service before MRI. That discussion delays imaging. Refer spinal surgery once compression is confirmed, or if MRI is not possible.
- Out-of-hours MRI access varies. Follow the local SOP for scanning or 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.
- Radiculopathy / sciatica: unilateral leg pain ± dermatomal sensory change; most do not need emergency MRI if there are 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.
CES features starting within 2 weeks
- Think of
- Emergency GIRFT route: MRI at presenting hospital
New bilateral sciatica, no CES features
- Think of
- Urgent MSK triage (2 weeks); safety-net
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 |
|---|---|
| CES features starting within 2 weeks | Emergency GIRFT route: MRI at presenting hospital |
| New bilateral sciatica, no CES features | Urgent MSK triage (2 weeks); safety-net |
| 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 if CES possible. If the patient cannot void and residual is >600 mL, catheterise, record whether the catheter is felt, and document a catheter tug. If they can void, record pre-void volume and post-void residual.
- GIRFT: residual >200 mL in suspected CES raises likelihood but must not be used alone to request or withhold MRI. Many operated CES patients have residual <200 mL.
- 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.
- Emergency MRI at the presenting hospital, in and out of hours. Request as soon as possible, and within 4 hours of the radiology request. A senior (ST4 or equivalent) should agree the request. Phone radiology for the emergency slot (see Requesting Radiology).
- MRI safety: tell MRI about implants, metal, and previous surgery early. If MRI is contraindicated, discuss CT or CT myelogram locally.
- 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 emergency MRI or senior review when the GIRFT emergency route applies.
- 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 mechanical pain. Encourage mobilisation as pain allows.
- Neuropathic agents may help radicular pain once serious pathology is excluded; follow local formulary.
- After MRI: if cauda equina compression is confirmed, refer spinal surgery immediately, stay nil by mouth, and arrange Category 2 ambulance transfer if the spinal centre is elsewhere.
- If MRI shows nerve-root compression explaining sciatica but not CES, safety-net and refer the MSK interface / triage service. If MRI is normal, think of other diagnoses.
- If discharging on the urgent route or without emergency imaging: give MACP CES warning-card advice (saddle change, urinary or bowel change, new sexual dysfunction, new bilateral weakness) and clear return instructions.
- Document neuro exam, subjective saddle sensation, bladder volumes, working diagnosis, senior discussions, and MRI request times.
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.
External resources
Note Template
Ready-to-use clinical note structure
🕒 08 / 10 / 2026 — 16:05 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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