What is the appropriate treatment protocol for a 44-year-old female patient with severe low back and radiating side pain, who strained her back earlier that morning, resulting in steadily worsening and now excruciating pain, and is being transported to the Emergency Room (ER) by ambulance?

Emergency Department Protocol for Severe Low Back Pain with Radiation

Immediately assess for red flag conditions requiring urgent intervention: cauda equina syndrome (urinary retention, fecal incontinence, bilateral leg weakness, saddle anesthesia), progressive neurologic deficits, or spinal cord compression. 1, 2

Initial Red Flag Assessment

Perform a focused history and examination targeting these critical findings:

• Cauda equina syndrome indicators: Ask specifically about urinary retention or incontinence, bowel incontinence, bilateral lower extremity weakness, and numbness in the saddle distribution (sensitivity 90%) 2
• Progressive neurologic deficits: Test for motor weakness, sensory loss in dermatomal distribution, and diminished deep tendon reflexes suggesting radiculopathy 1
• Straight-leg-raise test: Positive if sciatica is reproduced between 30-70 degrees of hip flexion with knee extended; a positive crossed straight-leg-raise (pain in affected leg when lifting unaffected leg) is highly specific for nerve root compression 1
• Additional red flags: History of cancer, recent spinal procedure, fever, unexplained weight loss, age >65 with trauma, long-term steroid use, or osteoporosis 1, 3, 4

Imaging Decision Algorithm

Do NOT obtain routine imaging if no red flags are present. 1

Obtain urgent MRI of the lumbar spine if:

• Any signs of cauda equina syndrome are present 5, 2
• Progressive or severe neurologic deficits exist 5, 2
• History of cancer with new severe back pain 5
• Suspected spinal cord compression 2

Consider plain radiography (not MRI) if:

• Risk factors for vertebral compression fracture exist (age >65, osteoporosis, steroid use) with midline tenderness 1, 2
• No neurologic symptoms but severe pain persists 1

MRI provides superior visualization for radiculopathy, disc herniation, spinal stenosis, and metastatic disease, but is not indicated for nonspecific low back pain without red flags. 5

Acute Pain Management Protocol

First-Line Pharmacologic Treatment

Initiate NSAIDs as first-line therapy for pain relief (more effective than acetaminophen by <10 points on 100-point visual analogue scale). 1

• Assess cardiovascular and gastrointestinal risk factors before prescribing NSAIDs due to increased myocardial infarction risk with COX-2 selective and most nonselective NSAIDs 1
• Use lowest effective dose for shortest duration necessary 1
• Consider co-administration with proton-pump inhibitor in higher-risk patients 1
• Acetaminophen is a reasonable alternative with more favorable safety profile but slightly weaker analgesic effect 1

Second-Line Options for Severe Pain

For severe, disabling pain not controlled by NSAIDs or acetaminophen, consider opioid analgesics or tramadol judiciously. 1

• Carefully weigh benefits versus substantial risks including aberrant drug-related behaviors with long-term use 1
• Use lowest dose for shortest time possible with close monitoring of efficacy and side-effects 1
• For IV morphine in elderly patients: Start with lower doses and titrate slowly; elderly patients are more susceptible to respiratory depression and have more variable pharmacodynamic effects 6
• Failure to respond to time-limited opioid course should prompt reassessment and consideration of alternative therapies 1

Skeletal muscle relaxants are an option for short-term relief but cause central nervous system adverse effects (primarily sedation). 1

Radicular Pain Specific Management

For patients with radicular symptoms (sciatica radiating below the knee), consider earlier specialist referral within 2 weeks if pain is severe or disabling. 1

• Radicular pain often responds poorly to simple analgesics and requires neuropathic pain medications 1
• Image-guided steroid injections can be considered for severe radicular pain based on patient choice and clinical appropriateness 1
• Referral to specialist services should occur no later than 3 months for less severe radicular pain 1

Disposition and Follow-Up

Avoid bed rest; encourage activity as tolerated. 3, 7

• Most patients with acute low back pain experience substantial improvement within the first month 1
• Reevaluate patients with persistent, unimproved symptoms after 1 month 1
• Earlier or more frequent reevaluation is appropriate for patients with severe pain, functional deficits, older age, or signs of radiculopathy/stenosis 1

Assess psychosocial factors as they are stronger predictors of outcomes than physical findings: depression, passive coping strategies, job dissatisfaction, disputed compensation claims, or somatization predict poorer outcomes and delayed recovery. 1, 2

Critical Pitfalls to Avoid

• Do not obtain MRI for nonspecific low back pain without red flags—this leads to identification of radiographic abnormalities poorly correlated with symptoms and potentially unnecessary interventions 1
• Do not prescribe long-term opioids without careful screening and awareness of potential problem use—international harm data supports tight restrictions 1
• Do not delay urgent MRI if cauda equina syndrome is suspected—delayed imaging may result in worsening outcomes including permanent neurologic deficits 5
• Do not assume all radiating pain requires imaging—most acute episodes are self-limited and resolve with conservative management 1