1. A&E MANAGEMENT OF NON- TRAUMATIC ACUTE LOW BACK PAIN
Inclusion criteria:
LS / low back pain
NERVE ROOT
MUSCLE ACTION
REFLEX L2
HIP FLEXION
L3,4
KNEE EXTENSION
KNEE
JERK
L4,5 S1
KNEE FLEXION L5
ANKLE +
BIG TOE DORSIFLEXION S1
ANKLE PLANTAR FLEXION
ANKLE
Exclusion criteria:
Significant history of trauma
Any suspicion of leaking AAA / thoracic dissection
History
Back + Lower Limb examination
Analgesia
ANY features of Cauda Equina?
Urinary / bowel / erectile dysfunction?
Gait disturbance ( NOT antalgic gait )
Reduced perianal or perineal sensation
Reduced anal tone
ANY red flags?
Non –mechanical pain (worse at night,
not related to movement, unremitting)
PMH of cancer, prolonged steroid use,
immunosuppression, HIV, IVDA,
First presentation <20 or >55 years
Fever, rigors
Weight loss
Structural spine abnormality
Minor trauma / heavy lifting
with osteoporosis NO
YES
D/W A&E senior (consultant if available)
for urgent MRI scan
Refer to Orthopaedics NO
YES
ANY features of nerve root pain?
Unilateral leg pain worse than back
Radiation to foot
Localised neurological signs
Leg pain reproduced on SLR
Numbness / parasthesia / weakness
matches pain radiation
Consider
FBC, U+Es, CRP, ESR, LFTs, bone profile
Blood cultures (if febrile)
L- spine x-ray
IV ABS if suspect discitis or abscess
Treat and refer as appropriate
YES NO
Diagnosis consistent with nerve root pain,
most settle spontaneously within 6/52
Give verbal advice:
Remain active, take regular analgesia
If no improvement after 1 month attend GP
Advise re: cauda equina, return immediately
to A&E if symptoms develop
Analgesia + mobilise
Asses if ANY apply:
- Pain requiring ongoing IV morphine OR
- Unable to mobilise + poor social support
YES
Refer orthopaedics NO
Discharge with back pain advice leaflet
and appropriate analgesia