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Atraumatic Back PainAPPROACH

BACK AND NECK · 19 SECTIONS

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773 items

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Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Atraumatic Back Pain Sciatica And Radicular Back Pain Back Pain With Neurologic Deficit, Cauda Equina Concern Back Pain With Fever Or Immunosuppression, Spinal Infection Concern Atraumatic Neck Pain Neck Pain After Trauma Neck Pain With Meningismus Concern Acute Torticollis

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx99

HPI overview

›Back pain context

›Location

›Cervical

›Thoracic

›Lumbar

›Sacral

›Pattern

›Constant

›Intermittent

›Progressive

›Waxing and waning

›Prior episodes

›Similar episode

›Different from baseline

›Functional impact

›Ambulation limitation

›Sleep disruption

›Work limitation

OPQRST

›OPQRST framework

›Onset

›Sudden

›Gradual

›Time course in days

›Time course in weeks

›Provocation and palliation

›Worse with flexion

02Alarm Features/alarm60

Immediate escalation triggers

›Time critical red flags

›Cauda equina syndrome concern

›New urinary retention symptoms

›New overflow incontinence

›New saddle anesthesia symptoms

›Progressive bilateral leg weakness

›Spinal epidural abscess concern

›Fever or rigors

›Immunocompromised state

›Injection drug use

›Severe focal spinal tenderness

›Malignancy concern

›History of cancer

›Unintentional weight loss

›Night pain not relieved by rest

›Fracture concern without trauma

›Age over 65

›Chronic systemic steroids

›Known osteoporosis

›Known metastatic disease

›Vascular catastrophe concern

›Abdominal pain with back pain

›Hypotension

›Syncope

›Known AAA

Vital sign danger thresholds

›High risk vital patterns

03Medications/meds36

Current and recent medications

›Medication reconciliation

›Prescription medications

›Anticoagulants

›Antiplatelets

›Chronic opioids

›Chronic benzodiazepines

›OTC medications

›Acetaminophen exposure

›NSAID exposure

›Supplements and herbals

›St Johns wort

›Kava

›Recent changes

›New medication started

›Dose increase

›Missed doses

High risk medication classes for back pain care

›Interaction and contraindication screen

›NSAID risk

›CKD history

›Peptic ulcer disease

›GI bleed history

›Anticoagulation use

›Sedative stacking risk

›Opioid use

›Benzodiazepine use

›Alcohol use

04Diet/diet21

Intake and hydration

›Recent intake

›Poor oral intake

›Dehydration risk

›NSAID risk increase

›Hydration status

›Low urine output

›Concentrated urine

Caffeine and stimulants

›Stimulant exposure

›Caffeine use

›High daily intake

›Abrupt cessation

›Energy drinks

›High dose use

›Palpitations association

Alcohol exposure

›Alcohol use context

›Heavy episodic use

›Fall risk

›Withdrawal risk

›Daily use

›Sedation interaction risk

›Liver disease risk

05Review of Systems/ros30

Constitutional and infection

›Constitutional

›Fever

›Chills

›Night sweats

›Weight loss

Neurologic

›Neurologic

›Weakness

›Numbness

›Paresthesias

›Gait instability

›Headache

Cardiorespiratory

›Cardiorespiratory

›Chest pain

›Dyspnea

›Syncope

›Palpitations

GI and GU

›GI and GU

›Abdominal pain

›Nausea

›Vomiting

›Dysuria

›Hematuria

›Urinary retention symptoms

›Incontinence

06Collateral History and Family History/chafh19

Collateral source

›Collateral and reliability

›Source

›Family

›Caregiver

›EMS

›Reliability concerns

›Intoxication

›Cognitive impairment

›Language barrier

Family history

›Family history risks

›Cancer syndromes

›Early onset malignancy

›Multiple first degree relatives affected

›Inflammatory arthritis

›Ankylosing spondylitis

›Psoriatic arthritis

›Aneurysm disease

›First degree relative AAA

›Known connective tissue disorder

07Risk Factors/rf35

Infection and immunosuppression

›Spine infection risk factors

›Injection drug use

›Recent use

›Prior endocarditis

›Indwelling access

›Hemodialysis catheter

›Long term central line

›Immunosuppression

›Diabetes mellitus (E11.9)

›HIV (B20)

›Biologic therapy

Malignancy and fracture

›Malignancy and fracture risks

›History of cancer

›Breast cancer (C50)

›Prostate cancer (C61)

›Lung cancer (C34)

›Multiple myeloma (C90.0)

›Osteoporosis risk

›Age over 65

›Chronic steroids

›Low BMI

›Vertebral compression fracture risk

›Prior compression fracture

›Known osteoporosis

Vascular and renal mimics

›Mimic risk factors

08Differential Diagnosis/ddx76

Life threatening

›Cannot miss diagnoses

›Cauda equina syndrome (G83.4)

›Urinary retention symptoms

›Saddle anesthesia symptoms

›Bilateral radicular symptoms

›Objective leg weakness

›Spinal epidural abscess (G06.1)

›Fever may be absent

›Severe focal tenderness

›IVDU or bacteremia risk

›Progressive neurologic deficit

›Vertebral osteomyelitis and discitis (M46.2)

›Persistent focal pain

›Elevated inflammatory markers

›Bacteremia risk factors

›Metastatic spinal cord compression (G95.20)

›History of cancer

›Progressive neurologic deficit

›Night pain

›Abdominal aortic aneurysm leak or rupture (I71.4)

›Abdominal pain

›Hypotension or syncope

›Pulsatile mass may be absent

›Retroperitoneal hemorrhage (R58)

›Anticoagulation use

›Hypotension

›Flank ecchymosis may be delayed

09Past Medical History/pmh30

Chronic conditions

›Relevant chronic disease

›Chronic kidney disease (N18.9)

›NSAID risk

›Contrast risk

›Peptic ulcer disease (K27.9)

›NSAID risk

›GI bleed risk

›Diabetes mellitus (E11.9)

›Spine infection risk

›Neuropathy baseline

›Osteoporosis (M81.0)

›Compression fracture risk

›Prior fractures

Prior spine history

›Spine history

›Prior surgery

›Laminectomy history

›Fusion history

›Prior injections

›Epidural steroid injection

›Facet injection

›Chronic radiculopathy

›Baseline dermatomes

›Baseline weakness

Devices and recent care

›Medical devices and recent admissions

›Implanted devices

10Physical Exam/exam63

General and vitals interpretation

›Initial assessment

›Appearance

›Toxic appearance

›Comfortable at rest

›Vitals pattern

›Fever pattern

›Sepsis physiology

›Hemodynamic instability

Back and spine exam

›Spine and musculoskeletal

›Inspection

›Posture

›Scoliosis

›Palpation

›Midline tenderness

›Paraspinal tenderness

›Step off deformity

›Range of motion

›Flexion limitation

›Extension limitation

›Pain localization

›Focal bony tenderness

›Diffuse muscular tenderness

Neurologic exam

›Focused neurologic

›Motor strength

›Hip flexion

11Lab Studies/labs37

Core labs when indicated

›Labs tied to red flags

›CBC

›Leukocytosis supports infection

›Normal CBC does not exclude spine infection

›CRP

›Elevated supports infection or inflammation

›Low CRP lowers probability of spinal infection

›ESR

›Elevated supports osteomyelitis

›Low ESR lowers probability but not zero

›Blood cultures

›Suspected spinal epidural abscess

›Suspected vertebral osteomyelitis

Renal and metabolic

›Metabolic and renal

›Creatinine and electrolytes

›NSAID safety context

›Contrast planning context

›Glucose

›Diabetes control context

›Infection risk marker

Urine and pregnancy

›Urine and pregnancy tests

›Urinalysis

›Hematuria supports stone

›Pyuria supports UTI

›Urine culture

12Imaging/img45

Scoring Systems

›Imaging decision frameworks

›Red flag based imaging criteria

›No imaging for uncomplicated acute low back pain under 6 weeks

›Imaging for severe or progressive neurologic deficit

›Imaging for suspected infection

›Imaging for suspected malignancy

›STarT Back Screening Tool use context

›Prognostic tool for persistent disability risk

›Not a rule out tool for life threats

MRI

›MRI spine

›Indications

›Cauda equina syndrome concern

›Severe or progressive neurologic deficit

›Suspected spinal infection

›Suspected malignancy or cord compression

›Protocol pearls

›Contrast for suspected infection or malignancy when feasible

›Whole spine imaging if multifocal symptoms

›Contraindications and limitations

›Non MRI compatible device

›Severe claustrophobia

›Early infection may be subtle

›CT spine and abdomen

›CT spine indications

›Suspected vertebral fracture

13Special Tests/spec24

Bedside maneuvers

›Provocative tests

›Straight leg raise

›Reproduction of radicular pain

›Pain below knee supports radiculopathy

›Crossed straight leg raise

›Higher specificity for disc herniation

›Reproduction on contralateral raise

›Femoral nerve stretch

›Anterior thigh pain suggests upper lumbar radiculopathy

›Use when symptoms above knee

Bladder assessment

›Urinary retention evaluation

›Post void residual when indicated

›Elevated supports cauda equina concern

›Normal does not fully exclude early disease

›Catheterization considerations

›Severe retention symptoms

›Monitor output

Procedural diagnostics

›Advanced testing pathways

›Lumbar puncture context

›Not routine for back pain

›Consider only when meningitis or SAH concern by alternate symptoms

›Image guided biopsy context

›Suspected vertebral osteomyelitis with negative cultures

›Specialty dependent pathway

14ECG/ecg20

When ECG matters in back pain

›ECG indications

›Back pain with chest pain

›Concern for ACS

›Concern for aortic syndrome

›Syncope or presyncope

›Arrhythmia screening

›Ischemia screening

›Significant hemodynamic instability

›Shock physiology

›Sepsis physiology

High risk patterns

›High risk ECG findings

›STEMI pattern

›Regional ST elevation

›Reciprocal changes

›Ischemia pattern

›New ST depression

›New T wave inversion

›Conduction and rhythm

›New wide complex tachycardia

›High grade AV block

15Assessment/ax35

Working diagnosis framework

›Problem representation

›Likely mechanical low back pain

›No red flags

›Normal neurologic exam

›Possible lumbar radiculopathy (M54.16)

›Dermatomal leg pain

›Positive straight leg raise

›Possible spinal stenosis (M48.06)

›Neurogenic claudication

›Relief with flexion

›Alternative diagnosis suspected

›Stone or pyelonephritis features

›AAA risk features

Severity and risk stratification

›Risk tier

›Low risk

›No red flags

›Stable vitals

›Reliable follow up

›Intermediate risk

›Significant pain limiting function

›Unclear neurologic symptoms without objective deficit

›High risk

›Objective neurologic deficit

›Infection or malignancy concern

›Hemodynamic instability

16Plan/plan70

First 5 minutes

›Critical patient workflow

›Monitoring

›Continuous pulse oximetry if unstable

›Cardiac monitor if syncope or hemodynamic concern

›IV access

›Two large bore IV for shock physiology

›One IV for parenteral analgesia if needed

›Oxygen

›Titrate to SpO2 target per local protocol dependent

›Escalate if respiratory distress

›Time critical imaging triggers

›If cauda equina concern then urgent MRI

›If hypotension with abdominal pain then immediate AAA ultrasound

›Early consult triggers

›Neurosurgery for cauda equina concern

›Spine surgery for suspected epidural abscess

Differential Management

›!Acute low back pain (mechanical)→›!Lumbar radiculopathy→

Analgesia and symptom control

›Analgesic pathway

›Acetaminophen

›PO 1000 mg once

›Maximum 3000 mg per day in older adult or liver disease risk

›NSAID option

›Ibuprofen PO 400 mg once

›Avoid with CKD

17Disposition/dispo51

Admission and higher level care

›Indications for ICU or resuscitation

›Hemodynamic instability

›Hypotension

›Lactate elevation if obtained

›Sepsis with organ dysfunction

›Altered mental status

›Hypoxemia

›Ruptured AAA concern

›Shock physiology

›Immediate surgical pathway

›Indications for inpatient admission

›Suspected spinal epidural abscess

›MRI confirmed or high suspicion

›IV antibiotics pathway

›Suspected vertebral osteomyelitis

›Systemic symptoms

›Elevated inflammatory markers

›Objective progressive neurologic deficit

›Surgical evaluation required

›Unsafe discharge

Observation pathway

›Observation appropriate when

›Pain control requires parenteral therapy

›Repeat dosing needed

›Functional assessment pending

›Diagnostic uncertainty

›Pending MRI availability

18Discharge Instructions/di16

Copy discharge instructions

›Discharge text

›You were seen for back pain without signs of a dangerous cause today

›Return to the emergency department now for new trouble peeing or inability to pee

›Return to the emergency department now for new numbness in the groin or buttock area

›Return to the emergency department now for new or worsening leg weakness

›Return to the emergency department now for fever or shaking chills with worsening back pain

›Return to the emergency department now for severe abdominal pain or fainting

›Pain control plan

›Acetaminophen as directed on the label

›NSAID only if safe for you and as directed on the label

›Activity

›Gentle movement as tolerated

›Avoid prolonged bed rest

›Follow up

›Primary care within 1 to 2 weeks

›Earlier follow up if symptoms worsen

19References/r6

Guidelines and key sources

›Evidence based sources

›American College of Physicians clinical practice guideline for noninvasive treatments for acute subacute and chronic low back pain 2017

›NICE guideline for low back pain and sciatica in over 16s assessment and management NG59 2016 with updates

›American College of Radiology Appropriateness Criteria low back pain most recent edition

›American College of Emergency Physicians clinical policies related to atraumatic back pain mimics local protocol dependent

›CDC guideline for prescribing opioids for pain 2022

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.