History

Presenting features

Symptom frame

Symptom trajectory

Functional impact

OPQRST

Onset

Provocation and palliation

Quality

Region and radiation

Severity

Timing

Associated symptoms

Neurologic symptoms

Cauda equina symptom cluster

Systemic symptoms

Infectious spine symptoms

Alarm Features

Immediate escalation triggers

Time critical neurologic red flags

Infection red flags

Malignancy red flags

Vascular red flags

Vital sign danger thresholds

Hemodynamic instability

Sepsis physiology

Respiratory compromise

High risk exam findings

High risk neurologic exam

Spinal instability concern

Compartment syndromes of spine

Medications

Current and recent

Current analgesics

Neuroactive agents

Recent medication changes

High risk medication classes

Bleeding risk medications

Immunosuppressing medications

Contraindications to common therapies

Diet

Hydration and intake context

Intake pattern

Hydration indicators

Exposures relevant to back pain care

Caffeine exposure

Alcohol exposure

Review of Systems

Neurologic

Motor and sensory symptoms

Autonomic symptoms

Infectious and inflammatory

Constitutional

Infection sources

MSK and other

Mechanical pattern

Alternative source symptoms

Collateral History and Family History

Collateral and reliability

Source

Reliability modifiers

Family history

Spine and neurologic

Vascular and connective tissue

Malignancy

Risk Factors

Infection and epidural abscess risk

Bacteremia risk

Immunocompromise

Procedure related

Spinal hematoma risk

Anticoagulation and coagulopathy

Trauma

Malignancy and fracture risk

Cancer history

Bone fragility

Differential Diagnosis

Life threatening

Cauda equina syndrome (G83.4)

Spinal epidural abscess (G06.1)

Metastatic spinal cord compression (G95.20)

Spinal epidural hematoma (G95.19)

Unstable vertebral fracture

Abdominal aortic aneurysm rupture (I71.3)

Common

Lumbar radiculopathy (M54.16)

Lumbar spinal stenosis (M48.06)

Mechanical low back pain (M54.50)

Herniated disc without cauda equina (M51.26)

Less common and mimics

Transverse myelitis (G37.3)

Guillain Barre syndrome (G61.0)

Psoas abscess (K68.12)

Renal colic (N20.0)

Hip pathology

Past Medical History

Relevant conditions

Prior spine disease

Neurologic baseline

Infection history

Procedures and devices

Spine procedures

Implanted devices

Physical Exam

Initial survey and vitals interpretation

General appearance

Vital sign patterns

Spine and MSK

Spine inspection and palpation

Range of motion tolerance

Focused neurologic exam

Motor

Sensory

Reflexes

Gait and coordination

Cauda equina and cord compression exam

Perineal and sphincter findings

Bladder assessment

Lab Studies

Core labs when red flags present

CBC

CRP

ESR

BMP

Targeted labs by scenario

Blood cultures

Coagulation studies

Pregnancy test

Lactate

Imaging

Scoring Systems

Decision support framework

When not to rely on low risk pathways

MRI

MRI spine priority pathway

Protocol considerations

Contraindications and workarounds

CT

CT indications

CT limitations

Contrast cautions

Ultrasound

Bladder ultrasound

Aorta ultrasound

Renal ultrasound

Special Tests

Bedside neurologic maneuvers

Straight leg raise

Crossed straight leg raise

Femoral nerve stretch test

Cauda equina focused bedside tests

Post void residual

Anal sphincter assessment

ECG

When relevant

Indications

High risk patterns

Assessment

Problem representation

Back pain with neurologic deficit

Working diagnoses and rule out priorities

Cauda equina syndrome rule out priority (G83.4)

Spinal epidural abscess rule out priority (G06.1)

Metastatic cord compression rule out priority (G95.20)

Severity stratification

Neurologic severity

Systemic severity

Plan

First 5 minutes

Stabilization and monitoring

Time critical actions

Diagnostic sequencing

Priority testing

Infection pathway when suspected

Hematoma pathway when suspected

Therapeutics

Analgesia

Cauda equina or cord compression support

Suspected spinal epidural abscess

Consultation and transfer

Spine service activation

Transfer triggers

Reassessment loop

Scheduled reassessment

Escalation triggers

Disposition

ICU and high acuity

ICU criteria

Stepdown criteria

Admission and observation

Inpatient admission

Observation pathway

Discharge criteria

Safe discharge requirements

Discharge Instructions

Copy discharge instructions

Summary

Medications

Activity

Follow up

Return to ED now for

References

Guidelines and key sources

Core references