What is the appropriate immediate management for a 26‑year‑old female presenting after hours with severe lower back pain, nausea, headache, jaw pain and inability to ambulate?

Immediate Emergency Department Evaluation Required

This 26-year-old woman requires immediate emergency department evaluation within hours, not days, due to the constellation of severe lower back pain, nausea, headache, jaw pain, and difficulty ambulating—a presentation that raises concern for serious neurological complications including spontaneous intracranial hypotension with CSF leak, epidural hematoma, or other urgent spinal pathology. 1

Critical Red Flags Present

This patient presents with multiple concerning features that mandate urgent assessment:

• Severe lower back pain with inability to ambulate suggests potential spinal cord or cauda equina involvement 1
• Headache combined with severe back pain and nausea is a classic presentation of spontaneous intracranial hypotension from CSF leak 1
• Jaw pain with headache may indicate meningeal irritation or referred pain from cervical pathology 2
• Nausea accompanying severe spinal pain can signal increased intracranial pressure changes or serious spinal pathology 1

Immediate After-Hours Management

Direct the Patient to Emergency Department

Advise immediate transport to the emergency department—do not wait until morning or schedule an outpatient appointment. 1, 3

The patient should:

• Not drive herself to the hospital 1
• Go by ambulance if unable to safely travel by car with assistance 3
• Be evaluated within 2-4 hours maximum given the severity and combination of symptoms 2, 4

Critical Conditions to Rule Out

The emergency department must urgently exclude:

Spontaneous Intracranial Hypotension (SIH)

• Presents with severe headache, back pain, nausea, and difficulty ambulating 1
• Requires brain MRI with contrast and whole spine MRI as initial imaging 1
• Can lead to serious complications including subdural hematoma and cerebral venous thrombosis if untreated 1

Epidural Hematoma or Abscess

• Severe localized back pain is present in most patients and often the first symptom 1
• Radiculopathy can cause radiating pain to jaw/head region 1
• Progressive neurological deficits can develop rapidly—paraparesis progressing to paraplegia 1
• Fever is present in only one-third of abscess cases, so absence does not exclude diagnosis 1

Cauda Equina Syndrome

• Severe back pain with difficulty walking raises this concern 1, 4
• Requires assessment for urinary retention, saddle anesthesia, and lower extremity weakness 1

Cervical Radiculopathy with Myelopathy

• Jaw pain radiating from occipital/cervical region with bilateral symptoms suggests high cervical pathology 2
• MRI cervical spine without contrast is the preferred imaging if red flags present 2

What to Tell the Patient Now

Provide clear, direct instructions:

1. "You need to go to the emergency department tonight—this combination of symptoms requires urgent evaluation to rule out serious spinal or neurological problems." 1, 3

2. "Do not drive yourself. Have someone take you or call an ambulance if you cannot safely get there." 1

3. "Tell the emergency department you have severe back pain with difficulty walking, headache, jaw pain, and nausea—these symptoms together need immediate imaging and evaluation." 1, 2

4. "Seek immediate attention if you develop any of the following before reaching the hospital: new leg weakness, numbness in the genital/rectal area, loss of bladder or bowel control, or worsening inability to walk." 1

Expected Emergency Department Workup

The emergency team should:

• Perform urgent MRI of brain with contrast and whole spine if SIH suspected 1
• MRI cervical and lumbar spine without contrast if epidural hematoma/abscess or radiculopathy suspected 1, 2
• Complete neurological examination including motor strength, sensory testing, reflexes, and rectal tone 1
• Assess for signs of meningeal irritation 1

Common Pitfalls to Avoid

• Do not reassure and schedule routine follow-up—this symptom constellation requires same-day/night evaluation 1, 2
• Do not assume this is simple musculoskeletal pain—the combination of headache, jaw pain, nausea, and inability to walk with severe back pain suggests serious pathology 1
• Do not delay imaging if red flags present—progressive neurological deficits are associated with worse outcomes when treatment is delayed 4
• Do not prescribe opioids and send home—this masks symptoms of potentially progressive neurological deterioration 1