approach to back pain


The vast majority of patients with back pain have a benign diagnosis, but our job in the ER is not to miss the few with serious causes. This means our approach should put mechanical back pain at the bottom of our differential, as we do with other extremity complaints. Traditional “red flags” for back pain include symptoms of infection, malignancy and spinal cord compression. But we also need to remember that the back is the posterior chest/abdomen, and need to consider a broader differential of emergent diagnoses.



  • Collapse lung
  • Effusion
  • Sick pneumonia
  • Tumour


  • RV strain: PE
  • Outflow dissection
  • Soft tissue bleed: AAA
  • Lactate: septic –> osteomyelitis, pyelo


  • myeLopathy: SCC, transverse myelitis




  • Biliary
  • Islet pancreatitis


  • epidural hematoma


J: joints, skin, bones

  • joints: arthritis
  • skin: zoster
  • bones: sciatica, spinal stenosis, vertebral fracture
  • muscle strain

Putting this together, a good history and physical (+/- bedside ultrasound) can eliminate most CHEST and ABDO causes of back pain, while red flags identify patients requiring advanced imaging for CARDIOVASCULAR/ NEUROLOGIC/HEME causes; after working through these considerations, most patients have musculoskeletal causes that can be treated with analgesia and followed up with their primary health provider.

  • B: ask about dyspnea, cough; listen to lungs
  • C: ask about PE risk factors and sudden/severe pain, assess for AAA and risk factors/symptoms of osteo/pyelo
  • D: ask about neuro/bladder/bowel symptoms and perform thorough physical exam; emergent MRI if signs of spinal cord compression
  • E
  • F
  • G: ask about abdominal pain and palpate abdomen
  • H: consider epidural hematoma if anti-coagulated
  • I
  • J: examine skin, bones, muscles; Xray if risk for fracture


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  1. Pingback: missed AAA |

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