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Back Pain With Neurologic Deficit, Cauda Equina ConcernAPPROACH

BACK AND NECK · 19 SECTIONS

⚲

561 items

☷ Legend

⚲

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/hx75

Presenting features

›Symptom frame

›Back pain with objective neurologic deficit

›Cauda equina concern

›Spinal cord compression concern

›Symptom trajectory

›Sudden onset

›Progressive over hours to days

›Subacute over days to weeks

›Chronic with acute worsening

›Functional impact

›Ambulation change

›Falls

›New assist devices

›Work and ADL impairment

OPQRST

›Onset

›Exact time of onset

›Trigger

›Lifting

›Twist

›Trauma

›Cough or sneeze

›Provocation and palliation

›Worse with

›Flexion

›Extension

›Valsalva

02Alarm Features/alarm40

Immediate escalation triggers

›Time critical neurologic red flags

›Suspected cauda equina syndrome

›Rapidly progressive motor deficit

›New bilateral leg weakness

›New bowel or bladder dysfunction

›Infection red flags

›Fever with back pain and neurologic deficit

›Severe focal spinal tenderness

›Recent bacteremia

›Malignancy red flags

›Known cancer with new back pain

›Night pain

›Unexplained weight loss

›Vascular red flags

›Syncope with back pain

›Hypotension with back pain

›Pulsatile abdominal mass

Vital sign danger thresholds

›Hemodynamic instability

›SBP under 90 mmHg

›Shock index over 1

›Sepsis physiology

›Temperature 38.0 C or higher

›Temperature under 36.0 C

›HR 120 or higher

›RR 22 or higher

›Respiratory compromise

03Medications/meds25

Current and recent

›Current analgesics

›Acetaminophen exposure

›NSAID exposure

›Opioid exposure

›Neuroactive agents

›Gabapentin exposure

›Pregabalin exposure

›Muscle relaxant exposure

›Recent medication changes

›New anticoagulant

›New antiplatelet

›Recent steroid burst

High risk medication classes

›Bleeding risk medications

›Warfarin

›DOAC

›Heparin products

›Dual antiplatelet therapy

›Immunosuppressing medications

›Chronic systemic corticosteroids

›Biologic agents

›Chemotherapy

›Contraindications to common therapies

›NSAID contraindication

›Opioid allergy history

›Serotonergic drug interactions

04Diet/diet14

Hydration and intake context

›Intake pattern

›Poor oral intake

›Vomiting limiting PO

›Normal intake

›Hydration indicators

›Oliguria

›Thirst

›Orthostasis symptoms

Exposures relevant to back pain care

›Caffeine exposure

›High intake

›Energy drinks

›Alcohol exposure

›Recent heavy use

›Withdrawal risk context

05Review of Systems/ros27

Neurologic

›Motor and sensory symptoms

›Weakness distribution

›Sensory level symptoms

›Paresthesias distribution

›New coordination issues

›Autonomic symptoms

›Urinary retention symptoms

›Urinary incontinence

›Bowel incontinence

›Sexual dysfunction

Infectious and inflammatory

›Constitutional

›Fever

›Chills

›Malaise

›Infection sources

›Skin and soft tissue infection

›Dental infection

›UTI symptoms

›Endocarditis symptoms

MSK and other

›Mechanical pattern

›Worse with movement

›Better with rest

›Alternative source symptoms

›Flank pain

›Abdominal pain

06Collateral History and Family History/chafh20

Collateral and reliability

›Source

›EMS

›Family

›Caregiver

›Chart review

›Reliability modifiers

›Intoxication

›Delirium

›Dementia

›Language barrier

Family history

›Spine and neurologic

›Inherited neuropathy

›Multiple sclerosis family history

›Vascular and connective tissue

›Aortic aneurysm family history

›Early CAD family history

›Malignancy

›Breast cancer

›Prostate cancer

›Hematologic malignancy

07Risk Factors/rf27

Infection and epidural abscess risk

›Bacteremia risk

›IVDU

›Indwelling vascular catheter

›Recent skin infection

›Immunocompromise

›Diabetes mellitus (E11.9)

›HIV

›Chronic kidney disease (N18.9)

›Chronic steroid use

›Procedure related

›Recent spinal procedure

›Epidural injection

›Recent surgery

Spinal hematoma risk

›Anticoagulation and coagulopathy

›Warfarin

›DOAC

›Thrombocytopenia

›Trauma

›Minor trauma in anticoagulated patient

›High energy trauma

Malignancy and fracture risk

›Cancer history

›Known metastatic disease

›New cancer symptoms

›Bone fragility

›Osteoporosis (M81.0)

08Differential Diagnosis/ddx50

Life threatening

›Cauda equina syndrome (G83.4)

›Urinary retention

›Saddle anesthesia

›Bilateral neurologic deficits

›Spinal epidural abscess (G06.1)

›Fever or systemic symptoms

›Elevated CRP

›Focal spinal tenderness

›Metastatic spinal cord compression (G95.20)

›Known malignancy

›Progressive weakness

›Night pain

›Spinal epidural hematoma (G95.19)

›Anticoagulation exposure

›Sudden severe pain

›Rapid neurologic decline

›Unstable vertebral fracture

›Trauma mechanism

›Osteoporosis risk

›Abdominal aortic aneurysm rupture (I71.3)

›Hypotension

›Abdominal pain

›Pulsatile mass

Common

›Lumbar radiculopathy (M54.16)

›Dermatomal pain

›Positive straight leg raise

09Past Medical History/pmh19

Relevant conditions

›Prior spine disease

›Prior disc herniation

›Prior stenosis

›Prior cauda equina episode

›Neurologic baseline

›Chronic neuropathy

›Prior stroke deficits

›Multiple sclerosis (G35)

›Infection history

›Prior endocarditis

›Prior osteomyelitis

Procedures and devices

›Spine procedures

›Surgery type

›Hardware present

›Recent epidural injection

›Implanted devices

›Spinal cord stimulator

›Pacemaker

›Cochlear implant

10Physical Exam/exam40

Initial survey and vitals interpretation

›General appearance

›Toxic appearance

›Pain behavior out of proportion

›Ability to ambulate

›Vital sign patterns

›Fever pattern

›Hypotension pattern

›Tachycardia pattern

Spine and MSK

›Spine inspection and palpation

›Midline tenderness

›Paraspinal tenderness

›Step off deformity

›Range of motion tolerance

›Flexion limited

›Extension limited

Focused neurologic exam

›Motor

›Hip flexion

›Knee extension

›Ankle dorsiflexion

›Great toe extension

›Plantarflexion

›Sensory

›Dermatomal light touch

›Pinprick when needed

›Saddle region sensation

11Lab Studies/labs24

Core labs when red flags present

›CBC

›Leukocytosis support for infection

›Anemia support for malignancy or bleeding

›CRP

›Elevated supports infection or inflammation

›Normal lowers likelihood of spinal epidural abscess but not zero

›ESR

›Elevated supports infection or malignancy

›Normal lowers likelihood of osteomyelitis but not zero

›BMP

›Renal function for contrast planning

›Electrolytes for weakness contributors

Targeted labs by scenario

›Blood cultures

›Fever with neurologic deficit

›Suspected spinal epidural abscess

›Coagulation studies

›INR for warfarin exposure

›Platelets for bleeding risk

›Pregnancy test

›Any patient with pregnancy potential

›Imaging and medication planning

›Lactate

›Sepsis physiology

›Shock physiology

12Imaging/img40

Scoring Systems

›Decision support framework

›Imaging indicated for objective neurologic deficit

›Imaging indicated for bowel or bladder dysfunction

›Imaging indicated for suspected spinal infection

›Imaging indicated for suspected malignancy compression

›When not to rely on low risk pathways

›Any progressive motor deficit

›Any saddle anesthesia

›Any urinary retention

MRI

›MRI spine priority pathway

›MRI urgent for suspected cauda equina syndrome

›MRI urgent for suspected spinal epidural abscess

›MRI urgent for suspected metastatic cord compression

›Protocol considerations

›Whole spine when sensory level or unclear localization

›Contrast when infection or malignancy suspected

›Noncontrast acceptable for disc herniation localization when infection unlikely

›Contraindications and workarounds

›Non MRI compatible implanted devices

›Severe claustrophobia

›CT myelogram consideration when MRI unavailable or contraindicated

›CT indications

›Trauma with suspected fracture

›Bony lesion evaluation

›When MRI unavailable and neurologic emergency requires interim imaging

13Special Tests/spec15

Bedside neurologic maneuvers

›Straight leg raise

›Reproduction of radicular pain supports nerve root irritation

›Limited utility for cauda equina exclusion

›Crossed straight leg raise

›Higher specificity for disc herniation

›Lower sensitivity

›Femoral nerve stretch test

›Anterior thigh pain supports upper lumbar radiculopathy

›Hip pathology mimic consideration

Cauda equina focused bedside tests

›Post void residual

›Marked retention supports cauda equina syndrome

›Normal value does not exclude early cauda equina syndrome

›Anal sphincter assessment

›Reduced tone supports cauda equina syndrome

›Inter examiner variability limitation

14ECG/ecg8

When relevant

›Indications

›Hypotension with back pain

›Chest pain symptoms

›Syncope

›High risk patterns

›STEMI

›New ischemic changes

›New conduction abnormality

15Assessment/ax26

Problem representation

›Back pain with neurologic deficit

›Localization

›Root pattern

›Cord pattern

›Peripheral nerve pattern

›Tempo

›Hyperacute

›Progressive hours to days

›Subacute weeks

Working diagnoses and rule out priorities

›Cauda equina syndrome rule out priority (G83.4)

›Urinary retention or overflow incontinence

›Saddle anesthesia

›Bilateral symptoms

›Spinal epidural abscess rule out priority (G06.1)

›Fever or elevated inflammatory markers

›Risk factors

›Metastatic cord compression rule out priority (G95.20)

›Cancer history

›Night pain and progressive weakness

Severity stratification

›Neurologic severity

›Motor deficit mild

›Motor deficit severe

›Nonambulatory

›Systemic severity

›Sepsis physiology

16Plan/plan60

Differential Management

›!Cauda equina syndrome→›!Spinal cord injury→›Malignant spinal cord compression→

First 5 minutes

›Stabilization and monitoring

›Airway concern triggers

›Altered mental status

›Respiratory failure

›Cardiorespiratory monitoring

›Continuous pulse oximetry

›Cardiac monitor when unstable

›IV access

›Two large bore peripheral IV when sepsis or instability

›Single IV acceptable when stable

›Time critical actions

›Emergent spine consultation trigger

›Suspected cauda equina syndrome

›Rapidly progressive motor deficit

›Early MRI pathway activation

›Contact MRI and radiology immediately when cauda equina suspected

›Transfer planning if MRI unavailable

Diagnostic sequencing

›Priority testing

›MRI spine per localization and red flags

›PVR measurement when bladder symptoms present

›Infection pathway when suspected

›Blood cultures before antibiotics when feasible

17Disposition/dispo22

ICU and high acuity

›ICU criteria

›Sepsis with vasopressor requirement

›Airway or respiratory compromise

›Rapid neurologic deterioration

›Stepdown criteria

›Frequent neurologic checks needed

›High risk infection requiring close monitoring

Admission and observation

›Inpatient admission

›Confirmed cauda equina syndrome

›Confirmed spinal epidural abscess

›Confirmed metastatic cord compression

›Uncontrolled pain with functional limitation

›Observation pathway

›Stable radiculopathy with controlled pain

›No red flags

›Reliable follow up

Discharge criteria

›Safe discharge requirements

›No objective motor deficit

›No bowel or bladder dysfunction

›Pain controlled with oral regimen

›Ambulation safe

›Follow up arranged

18Discharge Instructions/di22

Copy discharge instructions

›Summary

›Your symptoms today are most consistent with back pain with possible nerve irritation

›Your exam today did not show signs of spinal cord emergency

›Medications

›Acetaminophen as directed on the label

›Ibuprofen as directed on the label if safe for you

›Avoid alcohol or driving if using sedating pain medicines

›Activity

›Gentle walking as tolerated

›Avoid heavy lifting until improved

›Return to normal activity gradually as pain improves

›Follow up

›Primary care within 2 to 5 days

›Physiotherapy referral if symptoms persist

›Spine specialist follow up if worsening or persistent neurologic symptoms

›Return to ED now for

›Trouble starting urination

›New loss of bladder control

›New loss of bowel control

›Numbness in the groin or saddle area

›New or worsening leg weakness

›Fever with worsening back pain

19References/r7

Guidelines and key sources

›Core references

›American College of Radiology Appropriateness Criteria Low Back Pain 2021

›NICE guideline Low back pain and sciatica in over 16s assessment and management NG59 2016 updated

›Infectious Diseases Society of America guideline Vertebral Osteomyelitis in Adults 2015

›North American Spine Society guideline Lumbar Disc Herniation with Radiculopathy 2020

›National Comprehensive Cancer Network guideline Metastatic Spinal Cord Compression current version local protocol dependent

›Project instructions

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.

Back Pain With Neurologic Deficit, Cauda Equina ConcernAPPROACH

BACK AND NECK · 19 SECTIONS

⚲

561 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

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/hx75

Presenting features

›Symptom frame

›Back pain with objective neurologic deficit

›Cauda equina concern

›Spinal cord compression concern

›Symptom trajectory

›Sudden onset

›Progressive over hours to days

›Subacute over days to weeks

›Chronic with acute worsening

›Functional impact

›Ambulation change

›Falls

›New assist devices

›Work and ADL impairment

OPQRST

›Onset

›Exact time of onset

›Trigger

›Lifting

›Twist

›Trauma

›Cough or sneeze

›Provocation and palliation

›Worse with

›Flexion

›Extension

›Valsalva

02Alarm Features/alarm40

Immediate escalation triggers

›Time critical neurologic red flags

›Suspected cauda equina syndrome

›Rapidly progressive motor deficit

›New bilateral leg weakness

›New bowel or bladder dysfunction

›Infection red flags

›Fever with back pain and neurologic deficit

›Severe focal spinal tenderness

›Recent bacteremia

›Malignancy red flags

›Known cancer with new back pain

›Night pain

›Unexplained weight loss

›Vascular red flags

›Syncope with back pain

›Hypotension with back pain

›Pulsatile abdominal mass

Vital sign danger thresholds

›Hemodynamic instability

›SBP under 90 mmHg

›Shock index over 1

›Sepsis physiology

›Temperature 38.0 C or higher

›Temperature under 36.0 C

›HR 120 or higher

›RR 22 or higher

›Respiratory compromise

03Medications/meds25

Current and recent

›Current analgesics

›Acetaminophen exposure

›NSAID exposure

›Opioid exposure

›Neuroactive agents

›Gabapentin exposure

›Pregabalin exposure

›Muscle relaxant exposure

›Recent medication changes

›New anticoagulant

›New antiplatelet

›Recent steroid burst

High risk medication classes

›Bleeding risk medications

›Warfarin

›DOAC

›Heparin products

›Dual antiplatelet therapy

›Immunosuppressing medications

›Chronic systemic corticosteroids

›Biologic agents

›Chemotherapy

›Contraindications to common therapies

›NSAID contraindication

›Opioid allergy history

›Serotonergic drug interactions

04Diet/diet14

Hydration and intake context

›Intake pattern

›Poor oral intake

›Vomiting limiting PO

›Normal intake

›Hydration indicators

›Oliguria

›Thirst

›Orthostasis symptoms

Exposures relevant to back pain care

›Caffeine exposure

›High intake

›Energy drinks

›Alcohol exposure

›Recent heavy use

›Withdrawal risk context

05Review of Systems/ros27

Neurologic

›Motor and sensory symptoms

›Weakness distribution

›Sensory level symptoms

›Paresthesias distribution

›New coordination issues

›Autonomic symptoms

›Urinary retention symptoms

›Urinary incontinence

›Bowel incontinence

›Sexual dysfunction

Infectious and inflammatory

›Constitutional

›Fever

›Chills

›Malaise

›Infection sources

›Skin and soft tissue infection

›Dental infection

›UTI symptoms

›Endocarditis symptoms

MSK and other

›Mechanical pattern

›Worse with movement

›Better with rest

›Alternative source symptoms

›Flank pain

›Abdominal pain

06Collateral History and Family History/chafh20

Collateral and reliability

›Source

›EMS

›Family

›Caregiver

›Chart review

›Reliability modifiers

›Intoxication

›Delirium

›Dementia

›Language barrier

Family history

›Spine and neurologic

›Inherited neuropathy

›Multiple sclerosis family history

›Vascular and connective tissue

›Aortic aneurysm family history

›Early CAD family history

›Malignancy

›Breast cancer

›Prostate cancer

›Hematologic malignancy

07Risk Factors/rf27

Infection and epidural abscess risk

›Bacteremia risk

›IVDU

›Indwelling vascular catheter

›Recent skin infection

›Immunocompromise

›Diabetes mellitus (E11.9)

›HIV

›Chronic kidney disease (N18.9)

›Chronic steroid use

›Procedure related

›Recent spinal procedure

›Epidural injection

›Recent surgery

Spinal hematoma risk

›Anticoagulation and coagulopathy

›Warfarin

›DOAC

›Thrombocytopenia

›Trauma

›Minor trauma in anticoagulated patient

›High energy trauma

Malignancy and fracture risk

›Cancer history

›Known metastatic disease

›New cancer symptoms

›Bone fragility

›Osteoporosis (M81.0)

08Differential Diagnosis/ddx50

Life threatening

›Cauda equina syndrome (G83.4)

›Urinary retention

›Saddle anesthesia

›Bilateral neurologic deficits

›Spinal epidural abscess (G06.1)

›Fever or systemic symptoms

›Elevated CRP

›Focal spinal tenderness

›Metastatic spinal cord compression (G95.20)

›Known malignancy

›Progressive weakness

›Night pain

›Spinal epidural hematoma (G95.19)

›Anticoagulation exposure

›Sudden severe pain

›Rapid neurologic decline

›Unstable vertebral fracture

›Trauma mechanism

›Osteoporosis risk

›Abdominal aortic aneurysm rupture (I71.3)

›Hypotension

›Abdominal pain

›Pulsatile mass

Common

›Lumbar radiculopathy (M54.16)

›Dermatomal pain

›Positive straight leg raise

09Past Medical History/pmh19

Relevant conditions

›Prior spine disease

›Prior disc herniation

›Prior stenosis

›Prior cauda equina episode

›Neurologic baseline

›Chronic neuropathy

›Prior stroke deficits

›Multiple sclerosis (G35)

›Infection history

›Prior endocarditis

›Prior osteomyelitis

Procedures and devices

›Spine procedures

›Surgery type

›Hardware present

›Recent epidural injection

›Implanted devices

›Spinal cord stimulator

›Pacemaker

›Cochlear implant

10Physical Exam/exam40

Initial survey and vitals interpretation

›General appearance

›Toxic appearance

›Pain behavior out of proportion

›Ability to ambulate

›Vital sign patterns

›Fever pattern

›Hypotension pattern

›Tachycardia pattern

Spine and MSK

›Spine inspection and palpation

›Midline tenderness

›Paraspinal tenderness

›Step off deformity

›Range of motion tolerance

›Flexion limited

›Extension limited

Focused neurologic exam

›Motor

›Hip flexion

›Knee extension

›Ankle dorsiflexion

›Great toe extension

›Plantarflexion

›Sensory

›Dermatomal light touch

›Pinprick when needed

›Saddle region sensation

11Lab Studies/labs24

Core labs when red flags present

›CBC

›Leukocytosis support for infection

›Anemia support for malignancy or bleeding

›CRP

›Elevated supports infection or inflammation

›Normal lowers likelihood of spinal epidural abscess but not zero

›ESR

›Elevated supports infection or malignancy

›Normal lowers likelihood of osteomyelitis but not zero

›BMP

›Renal function for contrast planning

›Electrolytes for weakness contributors

Targeted labs by scenario

›Blood cultures

›Fever with neurologic deficit

›Suspected spinal epidural abscess

›Coagulation studies

›INR for warfarin exposure

›Platelets for bleeding risk

›Pregnancy test

›Any patient with pregnancy potential

›Imaging and medication planning

›Lactate

›Sepsis physiology

›Shock physiology

12Imaging/img40

Scoring Systems

›Decision support framework

›Imaging indicated for objective neurologic deficit

›Imaging indicated for bowel or bladder dysfunction

›Imaging indicated for suspected spinal infection

›Imaging indicated for suspected malignancy compression

›When not to rely on low risk pathways

›Any progressive motor deficit

›Any saddle anesthesia

›Any urinary retention

MRI

›MRI spine priority pathway

›MRI urgent for suspected cauda equina syndrome

›MRI urgent for suspected spinal epidural abscess

›MRI urgent for suspected metastatic cord compression

›Protocol considerations

›Whole spine when sensory level or unclear localization

›Contrast when infection or malignancy suspected

›Noncontrast acceptable for disc herniation localization when infection unlikely

›Contraindications and workarounds

›Non MRI compatible implanted devices

›Severe claustrophobia

›CT myelogram consideration when MRI unavailable or contraindicated

›CT indications

›Trauma with suspected fracture

›Bony lesion evaluation

›When MRI unavailable and neurologic emergency requires interim imaging

13Special Tests/spec15

Bedside neurologic maneuvers

›Straight leg raise

›Reproduction of radicular pain supports nerve root irritation

›Limited utility for cauda equina exclusion

›Crossed straight leg raise

›Higher specificity for disc herniation

›Lower sensitivity

›Femoral nerve stretch test

›Anterior thigh pain supports upper lumbar radiculopathy

›Hip pathology mimic consideration

Cauda equina focused bedside tests

›Post void residual

›Marked retention supports cauda equina syndrome

›Normal value does not exclude early cauda equina syndrome

›Anal sphincter assessment

›Reduced tone supports cauda equina syndrome

›Inter examiner variability limitation

14ECG/ecg8

When relevant

›Indications

›Hypotension with back pain

›Chest pain symptoms

›Syncope

›High risk patterns

›STEMI

›New ischemic changes

›New conduction abnormality

15Assessment/ax26

Problem representation

›Back pain with neurologic deficit

›Localization

›Root pattern

›Cord pattern

›Peripheral nerve pattern

›Tempo

›Hyperacute

›Progressive hours to days

›Subacute weeks

Working diagnoses and rule out priorities

›Cauda equina syndrome rule out priority (G83.4)

›Urinary retention or overflow incontinence

›Saddle anesthesia

›Bilateral symptoms

›Spinal epidural abscess rule out priority (G06.1)

›Fever or elevated inflammatory markers

›Risk factors

›Metastatic cord compression rule out priority (G95.20)

›Cancer history

›Night pain and progressive weakness

Severity stratification

›Neurologic severity

›Motor deficit mild

›Motor deficit severe

›Nonambulatory

›Systemic severity

›Sepsis physiology

16Plan/plan60

Differential Management

›!Cauda equina syndrome→›!Spinal cord injury→›Malignant spinal cord compression→

First 5 minutes

›Stabilization and monitoring

›Airway concern triggers

›Altered mental status

›Respiratory failure

›Cardiorespiratory monitoring

›Continuous pulse oximetry

›Cardiac monitor when unstable

›IV access

›Two large bore peripheral IV when sepsis or instability

›Single IV acceptable when stable

›Time critical actions

›Emergent spine consultation trigger

›Suspected cauda equina syndrome

›Rapidly progressive motor deficit

›Early MRI pathway activation

›Contact MRI and radiology immediately when cauda equina suspected

›Transfer planning if MRI unavailable

Diagnostic sequencing

›Priority testing

›MRI spine per localization and red flags

›PVR measurement when bladder symptoms present

›Infection pathway when suspected

›Blood cultures before antibiotics when feasible

17Disposition/dispo22

ICU and high acuity

›ICU criteria

›Sepsis with vasopressor requirement

›Airway or respiratory compromise

›Rapid neurologic deterioration

›Stepdown criteria

›Frequent neurologic checks needed

›High risk infection requiring close monitoring

Admission and observation

›Inpatient admission

›Confirmed cauda equina syndrome

›Confirmed spinal epidural abscess

›Confirmed metastatic cord compression

›Uncontrolled pain with functional limitation

›Observation pathway

›Stable radiculopathy with controlled pain

›No red flags

›Reliable follow up

Discharge criteria

›Safe discharge requirements

›No objective motor deficit

›No bowel or bladder dysfunction

›Pain controlled with oral regimen

›Ambulation safe

›Follow up arranged

18Discharge Instructions/di22

Copy discharge instructions

›Summary

›Your symptoms today are most consistent with back pain with possible nerve irritation

›Your exam today did not show signs of spinal cord emergency

›Medications

›Acetaminophen as directed on the label

›Ibuprofen as directed on the label if safe for you

›Avoid alcohol or driving if using sedating pain medicines

›Activity

›Gentle walking as tolerated

›Avoid heavy lifting until improved

›Return to normal activity gradually as pain improves

›Follow up

›Primary care within 2 to 5 days

›Physiotherapy referral if symptoms persist

›Spine specialist follow up if worsening or persistent neurologic symptoms

›Return to ED now for

›Trouble starting urination

›New loss of bladder control

›New loss of bowel control

›Numbness in the groin or saddle area

›New or worsening leg weakness

›Fever with worsening back pain

19References/r7

Guidelines and key sources

›Core references

›American College of Radiology Appropriateness Criteria Low Back Pain 2021

›NICE guideline Low back pain and sciatica in over 16s assessment and management NG59 2016 updated

›Infectious Diseases Society of America guideline Vertebral Osteomyelitis in Adults 2015

›North American Spine Society guideline Lumbar Disc Herniation with Radiculopathy 2020

›National Comprehensive Cancer Network guideline Metastatic Spinal Cord Compression current version local protocol dependent

›Project instructions

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.