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5 Low Back Pain Diagnoses You Don’t Want to Miss

blog_5LowBackPainDiagnoses_BackPainGeriatricExamDoc_260x200px.jpgOnly the common cold prompts more people to see a practitioner than acute low back pain. Most people will suffer with low back pain at least once in their lives, and it is estimated that 2% to 3% of all ED visits are for acute non-traumatic back pain. With costs exceeding $90 billion per year, the far-reaching implications are clear. Acute low back pain affects men and women of all ages; it is a common cause of disability in those less than 45 years of age due to work-related injury. Patients experience pain and lost wages; employers are impacted by loss of productivity in the workplace; and there is a major financial burden to society in general.

Although most acute back pain is mechanical and self-limited or appears to be an exacerbation of a previous back condition, the failure to recognize other potentially serious conditions may result in severe and permanent patient disability and sometimes death. Practitioners should be aware of key risk issues in order to improve patient care and reduce the incidence of medical errors, patient injury, and related litigation.

A careful approach to the history and physical examination with a sound medical decision-making process can help mitigate the risk of overlooking less common but serious causes of back pain such as cauda equina syndrome, occult infection, fracture, malignancy, or non-spine causes of back pain.

tom-syzekThe most common category of non-traumatic back pain consists of benign, self-limited musculoskeletal causes such as strains, sprains and uncomplicated disc herniation. The majority of these patients will recover with conservative measures and analgesia.

A second category of non-traumatic back pain includes non-spine causes such as those with renal, abdominal or thoracic etiologies. Here is an incomplete list of non-spine causes of low back pain:

  • Pelvic: Prostate, urinary, gynecologic
  • Renal: Stones, pyelonephritis, abscess
  • Abdominal Aortic Aneurysm (AAA)
  • Pancreatitis
  • Cholecystitis
  • Penetrating ulcer
  • Cardiac/pericardial
  • Pulmonary/pleural
  • Retroperitoneal bleed

A third category of back pain includes conditions that can cause severe and permanent neurologic disability. The challenge for the practitioner is to know the symptoms, signs and risk factors for these serious conditions and when to pursue additional diagnostic testing. Five of these serious causes are highlighted in the table below, along with key red flag features that should arouse the practitioner’s index of suspicion.

High-Risk Low Back Pain Diagnoses

Cauda Equina Syndrome
  • Severe, progressive bilateral leg pain with numbness or pain
  • Major motor weakness of lower extremity or foot drop
  • Sensory loss in genitals or perianal area
  • Changes in bladder or bowel function: urinary retention (up to 90% of patients with cauda equina syndrome), overflow incontinence, or loss of bowel control
Spinal Epidural Hematoma
  • Acute onset of pain, often localized
  • Recent procedure such as lumbar puncture or epidural injection
  • Neurologic findings at any spinal level (loss of strength, sensation)
  • Changes in bladder or bowel function (retention and/or incontinence)
  • Patient with coagulopathy, often secondary to anticoagulation or thrombolytic therapy
  • Age >50 years
  • History of cancer
  • Pain worse at night or when lying supine
  • Unexplained weight loss
  • Persistent or worsening pain lasting more than 4-6 weeks
Infection (Spinal Epidural Abscess, Vertebral Osteomyelitis, Diskitis)
  • Age >50 years increases risk
  • Insidious onset
  • Fever and/or chills; absence of fever does not rule out infection
  • Pain worse at night and unrelieved with rest
  • Recent skin or systemic infection (e.g., MRSA)
  • Immunosuppression, HIV, chronic steroid use
  • Intravenous or injected drug use
  • Recent spinal, genitourinary or gastrointestinal surgery or procedure
Fracture (Vertebral Compression Fracture)
  • History of trauma; high index of suspicion of fracture in elderly, even with mild trauma
  • Osteoporosis
  • Older age
  • Chronic steroid use


You may wonder how in the world you could pick out a serious condition in the sea of back pain patients that flows 24/7 into primary and acute care facilities. These patients do not come pre-labeled with the diagnosis of spinal epidural abscess or cauda equina syndrome. Instead, they come with the common complaint of pain in the back, and it is up to you to figure it out. Often they can hardly talk due to pain, much less move, which makes it difficult to get a history or perform a good exam. Their presentation often provokes a negative cognitive and emotional response from us as clinicians; the devil on our shoulder whispers in our ear: “Not another back pain!” or “What a wimp!” or “Just another drug seeker!”

So before you prescribe the NSAIDs, ice/heat and physical therapy for back pain patients and discharge them at record speed, listen instead to the angel on the other shoulder who whispers something like: “Take a breath and get a good history and exam!” and “Don’t forget the risk factors and red flags!” and “Keep your mind and differential diagnosis open!” and maybe even “Remember that all back pain is not just a strain.”

Learn more for CME

All of these concepts are covered in extensive detail in our online course:




Categories: Emergency Medicine, Patient Safety


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