What are the immediate precautions for patients presenting with back pain to the Emergency Room (ER)?

Emergency Room Precautions for Back Pain

When evaluating back pain in the ER, immediately screen for "red flags" indicating serious underlying pathology that requires urgent intervention—specifically severe or progressive neurologic deficits, cauda equina syndrome, spinal infection, fracture, malignancy, or aortic dissection.

Immediate Red Flag Assessment

Conduct a focused history and physical examination to identify conditions requiring emergent intervention 1:

Critical Red Flags Requiring Urgent Action

Neurologic emergencies:

• Progressive motor weakness or foot drop 1, 2
• Saddle anesthesia or perineal numbness 1
• Loss of bowel or bladder control/inability to void 1, 2
• Severe or progressive neurologic deficits in multiple nerve root distributions 1

Infectious/inflammatory conditions:

• Fever, chills, or recent infection with back pain 1, 3
• History of IV drug use or immunosuppression 3
• Vertebral osteomyelitis or spinal epidural abscess 3

Vascular emergencies:

• Suspicion of aortic dissection or ruptured abdominal aortic aneurysm 3
• Acute onset of severe pain with hemodynamic instability 3

Fracture risk:

• Age >65 years with trauma 1
• History of osteoporosis or chronic steroid use 1
• Recent significant trauma or fall from height 1

Malignancy:

• History of cancer 1, 3
• Unexplained weight loss 1
• Age >50 years with new onset pain and no improvement after 1 month 1

Imaging Decisions

Do not routinely obtain imaging for nonspecific low back pain 1. This is a strong recommendation based on moderate-quality evidence showing no improvement in patient outcomes with routine imaging and unnecessary radiation exposure 1.

Obtain immediate imaging (MRI preferred, or CT) when: 1

• Severe or progressive neurologic deficits are present 1
• Red flags suggest serious underlying conditions (infection, malignancy, fracture, cauda equina) 1
• Persistent radicular symptoms in patients who are surgical candidates 1

Plain radiography may be appropriate for suspected vertebral compression fracture in high-risk patients (osteoporosis, steroid use, significant trauma) 1.

Pain Management Approach

Avoid routine opioid prescribing for acute back pain 1. This is a Level C recommendation from the American College of Emergency Physicians 1.

Preferred analgesic strategy:

• First-line: NSAIDs (e.g., naproxen 500 mg twice daily or ibuprofen) for acute musculoskeletal pain 1, 2
• Screen for NSAID contraindications: cardiovascular disease, chronic renal failure, or previous GI bleeding 2
• Add acetaminophen 1000 mg every 6 hours for additional analgesia 2
• Avoid muscle relaxants like cyclobenzaprine—high-quality evidence shows no additional benefit when combined with NSAIDs 2

If opioids are deemed necessary:

• Prescribe the lowest indicated dose of short-acting opioids for the shortest feasible duration 1
• Discuss risks, benefits, and alternatives with the patient 1
• Do not routinely prescribe opioids for acute exacerbations of chronic noncancer pain 1

Critical Pitfalls to Avoid

Red flag questions have significant limitations 4. A 2018 study of 9,940 patients found that 64% of patients with spinal malignancy had no associated red flags, and the absence of red flags did not meaningfully decrease the likelihood of serious pathology 4. Therefore, maintain clinical suspicion even when screening questions are negative 4.

Avoid over-reliance on single red flags: For example, night pain alone was a false-positive for infection >96% of the time 4. Use combinations of red flags and clinical judgment rather than isolated findings 4.

Do not delay evaluation for severe radicular pain with neurologic deficit: Patients with disabling radicular pain or sensory/motor changes should be referred within 2 weeks of presentation for consideration of epidural steroid injections or surgery 1.

Disposition and Follow-Up

For nonspecific low back pain without red flags:

• Advise patients to remain active—bed rest is not recommended 1
• Provide reassurance about favorable prognosis (substantial improvement expected within first month) 1
• Recommend self-care with heat application for short-term relief 1
• Plan reassessment at 1 month if symptoms persist 1

For patients with red flags or neurologic deficits:

• Obtain urgent imaging and specialist consultation 1
• Consider admission for suspected cauda equina syndrome, spinal infection, or unstable fracture 3
• Arrange expedited follow-up within 2 weeks for severe radicular symptoms 1