Suspected infection or tumor causing back pain requires urgent workup. Patients at high risk of a condition requiring urgent investigation include those on immunosuppressive therapies, and those with a history of intravenous drug use.
Red flag signs and symptoms warranting urgent diagnostic imaging and referral to a spine specialist for ongoing management may include:[29]American College of Radiology. ACR appropriateness criteria: low back pain. 2021 [internet publication].
https://acsearch.acr.org/docs/69483/Narrative
http://www.ncbi.nlm.nih.gov/pubmed/34794594?tool=bestpractice.com
[30]Ramírez N, Olivella G, Valentín P, et al. Are constant pain, night pain, or abnormal neurological examination adequate predictors of the presence of a significant pathology associated with pediatric back pain? J Pediatr Orthop. 2019 Jul;39(6):e478-e481.
https://www.doi.org/10.1097/BPO.0000000000001353
http://www.ncbi.nlm.nih.gov/pubmed/30817418?tool=bestpractice.com
[31]American College of Radiology. ACR appropriateness criteria: acute spinal trauma. 2024 [internet publication].
https://acsearch.acr.org/docs/69359/Narrative
[32]American College of Radiology. ACR appropriateness criteria: suspected retroperitoneal bleed. 2021 [internet publication].
https://acsearch.acr.org/docs/3158181/Narrative
http://www.ncbi.nlm.nih.gov/pubmed/34794602?tool=bestpractice.com
[33]Henschke N, Maher CG, Refshauge KM. A systematic review identifies five "red flags" to screen for vertebral fracture in patients with low back pain. J Clin Epidemiol. 2008 Feb;61(2):110-18.
http://www.ncbi.nlm.nih.gov/pubmed/18177783?tool=bestpractice.com
[34]Han CS, Hancock MJ, Downie A, et al. Red flags to screen for vertebral fracture in people presenting with low back pain. Cochrane Database Syst Rev. 2023 Aug 24;8(8):CD014461.
http://www.ncbi.nlm.nih.gov/pubmed/37615643?tool=bestpractice.com
[35]Rossiter DJ, Haider Z, David B, et al. How not to miss major spinal pathology in patients with back pain. Br J Hosp Med (Lond). 2017 May 2;78(5):C66-9.
http://www.ncbi.nlm.nih.gov/pubmed/28489442?tool=bestpractice.com
[36]Maselli F, Palladino M, Barbari V, et al. The diagnostic value of red flags in thoracolumbar pain: a systematic review. Disabil Rehabil. 2022 Apr;44(8):1190-206.
http://www.ncbi.nlm.nih.gov/pubmed/32813559?tool=bestpractice.com
Saddle anesthesia
Sphincter disturbance (bladder or bowel dysfunction e.g. acute urinary retention, new onset urinary or fecal incontinence, loss of anal sphincter tone)
Profound or progressive neurologic deficit
History of malignancy with new onset back pain
Systemic ailments, including fever, chills, night sweats, and/or unexplained weight loss
Intravenous drug use
Urinary tract infection
Immunosuppression, including prolonged corticosteroid use or other immunosuppressive therapies
Trauma (including minor trauma in older adults)
Presence of contusion or abrasions over the spine
History of osteoporosis
Pain that is refractory to conservative management
Thoracic pain
Non-mechanical pain (i.e., systemic or referred causes of pain). Pain at rest and at night suggests a non-mechanical cause.
Age >50 years
Red flag signs and symptoms vary between guidelines.[37]Parreira PCS, Maher CG, Traeger AC, et al. Evaluation of guideline-endorsed red flags to screen for fracture in patients presenting with low back pain. Br J Sports Med. 2019 May;53(10):648-654.
https://www.doi.org/10.1136/bjsports-2018-099525
http://www.ncbi.nlm.nih.gov/pubmed/30337350?tool=bestpractice.com
Most guidelines endorse the red flags of history of malignancy, unexpected weight loss, significant trauma, prolonged corticosteroid use, fever and HIV.[5]Oliveira CB, Maher CG, Pinto RZ, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J. 2018 Nov;27(11):2791-2803.
https://www.doi.org/10.1007/s00586-018-5673-2
http://www.ncbi.nlm.nih.gov/pubmed/29971708?tool=bestpractice.com
[36]Maselli F, Palladino M, Barbari V, et al. The diagnostic value of red flags in thoracolumbar pain: a systematic review. Disabil Rehabil. 2022 Apr;44(8):1190-206.
http://www.ncbi.nlm.nih.gov/pubmed/32813559?tool=bestpractice.com
One systematic review of observational studies found that the presence of multiple red flags may increase diagnostic accuracy of thoracolumbar pain; the diagnostic accuracy of a single red flag as a self-contained screening tool was low.[36]Maselli F, Palladino M, Barbari V, et al. The diagnostic value of red flags in thoracolumbar pain: a systematic review. Disabil Rehabil. 2022 Apr;44(8):1190-206.
http://www.ncbi.nlm.nih.gov/pubmed/32813559?tool=bestpractice.com
Cauda equina syndrome
A presumed diagnosis of cauda equina syndrome necessitates an urgent workup. Bowel or bladder dysfunction, bilateral sciatica, and saddle anesthesia may be symptoms of severe compression of the cauda equina. Signs can include sensory changes in saddle or perianal area, sensory changes or numbness in the lower limbs, lower limb weakness, reduction or loss of reflexes in lower limbs and reduced anal tone.
The etiology is usually a large central herniated disk or a pathologic or traumatic fracture, causing compression of the cauda equina.
A complete history, physical exam and urgent diagnostic imaging should identify impending neurologic compromise and the need for emergent referral to a spinal surgeon.[29]American College of Radiology. ACR appropriateness criteria: low back pain. 2021 [internet publication].
https://acsearch.acr.org/docs/69483/Narrative
http://www.ncbi.nlm.nih.gov/pubmed/34794594?tool=bestpractice.com
Spinal cord compression
Spinal cord compression (SCC) can occur as a result of spine trauma, vertebral compression fracture, intervertebral disk herniation, primary or metastatic spinal tumor, or infection. Acute SCC is a medical emergency that requires swift diagnosis and treatment to prevent irreversible spinal cord injury and long-term disability. Clinicians should maintain a high index of suspicion for SCC in patients with a history of malignancy and back pain.
Symptoms and signs depend on the level of spinal cord compression. Patients may report sensory symptoms of altered sensation below a certain level or hemisensory loss; motor symptoms of hemiplegia/hemiparesis, paraplegia/paraparesis or tetraplegia/tetraparesis; and/or autonomic symptoms including constipation and urinary retention. Examination may detect motor weakness, a sensory level and altered reflexes. Hyper-reflexia and loss of pinprick sensation, temperature, position, and vibratory sensation may occur early, especially when associated with malignancy.
Urgent MRI or CT imaging is indicated.[31]American College of Radiology. ACR appropriateness criteria: acute spinal trauma. 2024 [internet publication].
https://acsearch.acr.org/docs/69359/Narrative
[38]American College of Radiology. ACR appropriateness criteria: suspected spine infection. 2021 [internet publication].
https://acsearch.acr.org/docs/3148734/Narrative
http://www.ncbi.nlm.nih.gov/pubmed/34794603?tool=bestpractice.com
[39]National Institute for Health and Care Excellence. Spinal metastases and metastatic spinal cord compression. Sep 2023 [internet publication].
https://www.nice.org.uk/guidance/ng234
Treatment of acute spinal cord compression is typically with surgery.[39]National Institute for Health and Care Excellence. Spinal metastases and metastatic spinal cord compression. Sep 2023 [internet publication].
https://www.nice.org.uk/guidance/ng234
Corticosteroids and/or radiotherapy may also be used, particularly for spinal cord compression caused by malignancy.[39]National Institute for Health and Care Excellence. Spinal metastases and metastatic spinal cord compression. Sep 2023 [internet publication].
https://www.nice.org.uk/guidance/ng234
Trauma
CT imaging of the cervical and thoracolumbar spine is the preferred test for patients with midline tenderness, a high energy mechanism of injury, or those who are >60 years with a mechanism of injury consistent with thoracolumbar spine injury.[31]American College of Radiology. ACR appropriateness criteria: acute spinal trauma. 2024 [internet publication].
https://acsearch.acr.org/docs/69359/Narrative
CT may also be required in patients who cannot be examined due to intoxication, Glasgow Coma Score <15‚ or a distracting injury.[31]American College of Radiology. ACR appropriateness criteria: acute spinal trauma. 2024 [internet publication].
https://acsearch.acr.org/docs/69359/Narrative
Neurologic compromise, gross spinal deformities or manual step off on spinal palpation also warrant CT.
CT has a higher sensitivity for detecting fractures of the thoracolumbar spine than plain radiographs and also identifies soft tissue injuries that often accompany spinal fractures.[31]American College of Radiology. ACR appropriateness criteria: acute spinal trauma. 2024 [internet publication].
https://acsearch.acr.org/docs/69359/Narrative
[40]Bailitz J, Starr F, Beecroft M, et al. CT should replace three-view radiographs as the initial screening test in patients at high, moderate, and low risk for blunt cervical spine injury: a prospective comparison. J Trauma. 2009 Jun;66(6):1605-9.
https://www.doi.org/10.1097/TA.0b013e3181a5b0cc
http://www.ncbi.nlm.nih.gov/pubmed/19509621?tool=bestpractice.com
Imaging of the entire spine is recommended because approximately 20% of patients with spinal fracture have a second noncontiguous fracture.[31]American College of Radiology. ACR appropriateness criteria: acute spinal trauma. 2024 [internet publication].
https://acsearch.acr.org/docs/69359/Narrative
If plain radiographs are obtained, anteroposterior and lateral views are required. A “swimmer’s lateral” view should be obtained if the shoulders obscure the upper thoracic spine.[31]American College of Radiology. ACR appropriateness criteria: acute spinal trauma. 2024 [internet publication].
https://acsearch.acr.org/docs/69359/Narrative
Of note, spinal precautions should be taken when moving trauma patients until the spine is cleared by the trauma or spinal surgeon. If any abnormalities are noted on imaging, a spinal surgeon should be consulted for further management.
Epidural abscess
This rare condition is characterized by inflammation with pus within the epidural space.
Risk factors for epidural abscess include diabetes mellitus, intravenous drug use, an immunocompromised state, recent spinal surgery or trauma, presence of indwelling spinal catheter, pre-existing infection (in contiguous tissue or distant infection causing bacteremia), dialysis and alcohol misuse.[27]Alerhand S, Wood S, Long B, et al. The time-sensitive challenge of diagnosing spinal epidural abscess in the emergency department. Intern Emerg Med. 2017 Dec;12(8):1179-83.
http://www.ncbi.nlm.nih.gov/pubmed/28779448?tool=bestpractice.com
Spinal epidural abscess can present with fever, back or neck pain, and neurologic deficits. However, this triad of symptoms is only present in 10% to 15% of cases and therefore having a low threshold for considering this diagnosis in patients at risk is crucial.[27]Alerhand S, Wood S, Long B, et al. The time-sensitive challenge of diagnosing spinal epidural abscess in the emergency department. Intern Emerg Med. 2017 Dec;12(8):1179-83.
http://www.ncbi.nlm.nih.gov/pubmed/28779448?tool=bestpractice.com
Back or neck pain is the most common symptom in individuals with spinal epidural abscess, occurring in 70% to 100% of cases.[41]Reihsaus E, Waldbaur H, Seeling W. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev. 2000 Dec;23(4):175-204.
http://www.ncbi.nlm.nih.gov/pubmed/11153548?tool=bestpractice.com
Pain is increased with weight-bearing and not relieved by rest.
Neurologic loss develops rapidly. Patients require urgent investigation with MRI (without and with contrast).[38]American College of Radiology. ACR appropriateness criteria: suspected spine infection. 2021 [internet publication].
https://acsearch.acr.org/docs/3148734/Narrative
http://www.ncbi.nlm.nih.gov/pubmed/34794603?tool=bestpractice.com
The use of an intravenous contrast agent increases lesion conspicuity, and helps to define the extent of the infectious process.[38]American College of Radiology. ACR appropriateness criteria: suspected spine infection. 2021 [internet publication].
https://acsearch.acr.org/docs/3148734/Narrative
http://www.ncbi.nlm.nih.gov/pubmed/34794603?tool=bestpractice.com
[42]Diehn FE. Imaging of spine infection. Radiol Clin North Am. 2012 Jul;50(4):777-98.
https://www.doi.org/10.1016/j.rcl.2012.04.001
http://www.ncbi.nlm.nih.gov/pubmed/22643395?tool=bestpractice.com
For all patients, treatment includes empirical and subsequent culture-directed definitive antibiotic therapy.
For patients with neurologic deficit, decompressive surgery is essential. In these patients, the single most important predictor of the final neurologic outcome is the patient's neurologic status immediately before decompressive surgery.
Acute pancreatitis
Typically presents with sudden-onset mid-epigastric or left upper quadrant abdominal pain, which often radiates to the back (usually the lower thoracic area but can be a band-like wraparound pattern).[43]Johnson CD, Besselink MG, Carter R. Acute pancreatitis. BMJ. 2014 Aug 12;349:g4859.
http://www.ncbi.nlm.nih.gov/pubmed/25116169?tool=bestpractice.com
Classically, the pain is relieved when the patient leans forward. Often there are associated symptoms of nausea and vomiting. Patients may have fever, jaundice, tachycardia and/or tenderness and guarding of the abdomen. Risk factors include gallstones and excessive alcohol intake.
Diagnosis is confirmed by the presence of two of the following:[44]Tenner S, Vege SS, Sheth SG, et al. American College of Gastroenterology guidelines: management of acute pancreatitis. Am J Gastroenterol. 2024 Mar 1;119(3):419-37.
https://journals.lww.com/ajg/fulltext/2024/03000/american_college_of_gastroenterology_guidelines_.14.aspx
http://www.ncbi.nlm.nih.gov/pubmed/38857482?tool=bestpractice.com
abdominal pain consistent with acute pancreatitis,
serum lipase or amylase >3 times the upper limit of normal,
and/or characteristic findings from abdominal imaging.
Serum lipase and amylase have similar sensitivity and specificity but lipase levels remain elevated for longer (up to 14 days after symptom onset vs. 5 days for amylase), providing a higher likelihood of picking up the diagnosis in patients with a delayed presentation.[44]Tenner S, Vege SS, Sheth SG, et al. American College of Gastroenterology guidelines: management of acute pancreatitis. Am J Gastroenterol. 2024 Mar 1;119(3):419-37.
https://journals.lww.com/ajg/fulltext/2024/03000/american_college_of_gastroenterology_guidelines_.14.aspx
http://www.ncbi.nlm.nih.gov/pubmed/38857482?tool=bestpractice.com
[45]Rompianesi G, Hann A, Komolafe O, et al. Serum amylase and lipase and urinary trypsinogen and amylase for diagnosis of acute pancreatitis. Cochrane Database Syst Rev. 2017 Apr 21;(4):CD012010.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012010.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/28431198?tool=bestpractice.com
Assess hemodynamic status and resuscitate the patient with crystalloid intravenous fluids. Use a moderate goal-directed fluid replacement strategy for the best overall patient outcomes; both overly aggressive and overly conservative fluid therapy can cause harm in acute pancreatitis.[46]van Dijk SM, Hallensleben NDL, van Santvoort HC, et al. Acute pancreatitis: recent advances through randomised trials. Gut. 2017 Nov;66(11):2024-32.
http://www.ncbi.nlm.nih.gov/pubmed/28838972?tool=bestpractice.com
[47]de-Madaria E, Buxbaum JL, Maisonneuve P, et al. Aggressive or moderate fluid resuscitation in acute pancreatitis. N Engl J Med. 2022 Sep 15;387(11):989-1000.
https://www.nejm.org/doi/10.1056/NEJMoa2202884
http://www.ncbi.nlm.nih.gov/pubmed/36103415?tool=bestpractice.com
Guidelines differ in their specific recommendations; check local protocols.
Assess for signs of organ dysfunction immediately on presentation, particularly cardiovascular, respiratory, or renal. Systemic inflammatory response syndrome (SIRS) and/or multi-organ failure are the biggest risk to life in the first week. Consider intensive care unit transfer (or transfer to a monitored bed setting) for any patient who has SIRS or early signs of organ failure.[44]Tenner S, Vege SS, Sheth SG, et al. American College of Gastroenterology guidelines: management of acute pancreatitis. Am J Gastroenterol. 2024 Mar 1;119(3):419-37.
https://journals.lww.com/ajg/fulltext/2024/03000/american_college_of_gastroenterology_guidelines_.14.aspx
http://www.ncbi.nlm.nih.gov/pubmed/38857482?tool=bestpractice.com
Treat pain promptly using a standard "pain ladder" approach.[46]van Dijk SM, Hallensleben NDL, van Santvoort HC, et al. Acute pancreatitis: recent advances through randomised trials. Gut. 2017 Nov;66(11):2024-32.
http://www.ncbi.nlm.nih.gov/pubmed/28838972?tool=bestpractice.com
Opioids may be needed for effective pain control.[48]Basurto Ona X, Rigau Comas D, Urrútia G. Opioids for acute pancreatitis pain. Cochrane Database Syst Rev. 2013 Jul 26;(7):CD009179.
https://www.doi.org/10.1002/14651858.CD009179.pub2
http://www.ncbi.nlm.nih.gov/pubmed/23888429?tool=bestpractice.com
Ruptured abdominal aortic aneurysm
Patients with the triad of abdominal and/or back pain, pulsatile abdominal mass, and hypotension warrant immediate resuscitation and surgical evaluation as repair offers the only potential cure.[49]Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. 2018 Jan;67(1):2-77.e2.
https://www.jvascsurg.org/article/S0741-5214(17)32369-8/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/29268916?tool=bestpractice.com
Initiate standard resuscitation measures immediately, including:
Airway management (supplemental oxygen and endotracheal intubation and assisted ventilation if the patient is unconscious).
Intravenous access (central venous catheter).
Arterial catheter; urinary catheter.
Hypotensive resuscitation: aggressive fluid replacement may cause dilutional and hypothermic coagulopathy and secondary clot disruption from increased blood flow, increased perfusion pressure, and decreased blood viscosity, thereby exacerbating bleeding. A target systolic BP of 50 to 70 mmHg and withholding fluids is advocated preoperatively.[50]Roberts K, Revell M, Youssef H, et al. Hypotensive resuscitation in patients with ruptured abdominal aortic aneurysm. Eur J Vasc Endovasc Surg. 2006 Apr;31(4):339-44.
https://www.ejves.com/article/S1078-5884(05)00696-9/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/16388972?tool=bestpractice.com
The US guidelines recommend permissive hypotension to reduce bleeding.[51]Isselbacher EM, Preventza O, Hamilton Black J 3rd, et al. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on clinical practice guidelines. Circulation. 2022 Dec 13;146(24):e334-482.
https://www.ahajournals.org/doi/10.1161/CIR.0000000000001106
http://www.ncbi.nlm.nih.gov/pubmed/36322642?tool=bestpractice.com
However, recommended targets vary and there is no consensus among global guideline groups.[52]Wanhainen A, Van Herzeele I, Bastos Goncalves F, et al. Editor's choice -- European Society for Vascular Surgery (ESVS) 2024 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms. Eur J Vasc Endovasc Surg. 2024 Feb;67(2):192-331.
https://www.ejves.com/article/S1078-5884(23)00889-4/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/38307694?tool=bestpractice.com
Blood product (packed red cells, platelets, and fresh frozen plasma) availability and transfusion for resuscitation, severe anemia, and coagulopathy.