THE CHIEF
COMPLAINT

Orthopedics

Low Back Pain

Start by deciding whether this is a spinal emergency, referred pain, or a mechanical / root syndrome. The history and examination determine which question needs imaging—not the pain score alone. Once serious causes are reasonably excluded, the goal is safe function and a workable follow-up plan, not proving which muscle or disc hurts. Resuscitation, diagnostic assessment, and consultation proceed together when an emergency is suspected.

The Algorithm...

01 Initial Assessment / Red Flags

  • Unstable? Shock, poor perfusion, or toxic appearance → resuscitate while assessing vascular catastrophe or sepsis
  • What Changed? Trauma, new weakness, bladder / bowel / saddle symptoms, infection risk, or cancer history. Compare with baseline; examine the abdomen, spine, pulses, and neurologic function. See Initial Assessment

02 R/O Emergent Diagnoses

  • Vascular? Abrupt severe back / abdominal pain, syncope, or pulse abnormalities → assess AAA / dissection. Bedside US for suspected AAA; CTA when safe + early vascular / aortic-team involvement. See Aortic Assessment
  • Compression? New bladder / bowel / saddle symptoms or new substantial OR progressive motor weakness → urgent MRI + spine consultation. Low PVR does not exclude CES. See Cauda Equina
  • Spinal Infection? Concerning focal spine pain + infection context → assess for SEA / vertebral infection. High suspicion → MRI + cultures / ESR / CRP; neurologic deficit or sepsis → urgent spine consultation + IV antibiotics. Do not wait for the classic triad or laboratory results. See Spinal Infection
  • Fracture? Trauma or focal vertebral pain + fracture risk → spine imaging. CT / MRI according to injury and neurologic findings; suspected instability or neurologic deficit → spine consultation. See Fracture

03 Visceral Cause?

  • Urinary? Flank / groin pain, dysuria, fever, or CVA tenderness → assess pyelonephritis, stone, and obstruction. UA / culture, renal function, and imaging according to the question. See Pyelonephritis / Renal Colic
  • Infected Obstruction? IV antibiotics + urgent urologic drainage—not antibiotics alone
  • Pregnancy + Suspected Pyelonephritis? OB consultation + initial inpatient treatment
  • GI / Pelvic? Abdominal findings, bleeding, discharge, or possible pregnancy → targeted abdominal / pelvic assessment. See Visceral Causes

04 Mechanical Pain / Radiculopathy?

  • Radiculopathy? Match radiating pain, strength, sensation, and reflexes to a root. A single-root pattern does not make new substantial or progressive weakness safe for discharge
  • No Unresolved Serious Concern? Encourage activity, treat pain to improve safe movement, and arrange follow-up. Immediate imaging is usually unnecessary. See Mechanical Pain

05 Reassess / Disposition

  • Repeat strength, gait, evolving bladder / saddle symptoms, systemic findings, and symptom control
  • Discharge: Reassuring assessment, manageable symptoms, safe function, and reliable follow-up
  • Monitored Admission: Unresolved concern, required investigation / treatment, or unsafe function
  • ICU Admission: Shock, critical support needs, or deterioration requiring intensive monitoring
  • Definitive Care: Necessary decompression, vascular intervention, or urinary drainage must not wait for a routine inpatient bed. See Disposition

Initial Assessment / Red Flags

Stable Or Unstable?

  • Shock / Toxic Appearance? Assess BP, pulse, perfusion, temperature, and mental status. Resuscitate and identify the cause before labeling the pain musculoskeletal.
  • What Is Different Today? Establish onset, location, radiation, trauma, and prior episodes. Compare strength, gait, and bladder function with baseline; a change from chronic pain may be more important than the pain score.
  • Background: Review anticoagulants, corticosteroids, recent spinal procedures, infection / bacteremia, cancer, and immunosuppression.

What Moves The Needle?

  • Compression: New substantial or progressive weakness, gait change, saddle / genital sensory change, or new bladder, bowel, or sexual dysfunction.
  • Infection: Bacteremia / distant infection, injection drug use, spinal procedure, indwelling catheter, or immunocompromise.
  • Malignancy: Prior cancer, progressive unexplained pain, weight loss, or neurologic change.
  • Fracture: Trauma, osteoporosis, older age, or prolonged steroid exposure.
  • Vascular: Abrupt severe back / abdominal pain, syncope, shock, or pulse / neurologic abnormalities.
  • Visceral: Flank / abdominal pain, urinary symptoms, GI bleeding, pelvic symptoms, or pregnancy possibility.
  • Interpret The Pattern: Age over 50, night pain, or duration alone does not mandate emergency MRI. Findings matter in combination and in context. A reassuring checklist does not override a concerning clinical pattern. Downie 2013 · Han 2023.

Focused Examination

  • Spine: Distinguish midline from paraspinal tenderness; assess relevant trauma or procedural findings.
  • Neurologic: Compare bilateral strength, sensation, reflexes, and gait when safe. Distinguish pain-limited movement from objective weakness.
  • Sacral Function: Ask directly about perineal / genital sensation and sphincter symptoms. “No incontinence” is not a complete CES assessment. See Compression.
  • Outside The Spine: Examine the abdomen, pulses, and costovertebral angles. Pelvic symptoms warrant targeted examination; back pain does not establish a spinal source.

Testing — Which Question Needs An Answer?

  • Suspected Compression / Infection / Malignancy: MRI answers the soft-tissue and neural-compression question. Select the region and contrast protocol for the suspected process; a normal lumbar x-ray does not exclude these diagnoses.
  • Suspected Fracture: Radiography / CT according to the injury and fracture risk; MRI for neurologic involvement or an unresolved occult injury.
  • Reassuring Uncomplicated Pain: Usually no immediate imaging. Persistent symptoms require reassessment and imaging when it will change management—not emergency MRI solely because six weeks have elapsed. ACR/RSNA — Imaging.

R/O Emergent Diagnoses

AAA / Aortic Dissection — Recognize And Redirect

  • AAA / Rupture? Abrupt back / abdominal pain, syncope, or shock with vascular risk → assess for AAA. A rupture may resemble renal colic. Bedside US can identify an aneurysm but does not exclude rupture.
    • Suspected Rupture: Vascular consultation + hemorrhage resuscitation. Obtain CTA when the patient can safely undergo imaging and the result will guide care; do not delay necessary intervention.
    • See Abdominal Pain: General — AAA for the main disease section.
  • Aortic Dissection? Abrupt severe pain with pulse abnormalities, neurologic findings, or limb ischemia → urgent aortic imaging + aortic-team involvement. Choose imaging according to stability; a lumbar study does not answer this question.

Cauda Equina / Conus / Cord Compression

What Is Cauda Equina Syndrome?

  • Anatomy: The spinal cord ends in the upper lumbar spine. Lumbar and sacral roots continue below it as the cauda equina, serving the legs, saddle region, and pelvic organs. AANS — Cauda Equina.
  • Cauda Equina Syndrome — CES: Sacral-root dysfunction affecting bladder, bowel, saddle sensation, or sexual function. Back pain, sciatica, and leg weakness may accompany it, but preserved walking or voluntary urination does not exclude developing CES. The key question is whether pelvic / sacral function has changed.
  • Cause: Usually a large lumbar disc herniation; other causes include stenosis, tumor, epidural infection, hemorrhage, or trauma. CES identifies the neurologic syndrome—not the underlying cause. Lavy 2022.
  • Conus / Cord: The conus is the terminal spinal cord and can produce overlapping leg / sphincter findings. A sensory level requires assessment beyond an isolated lumbar root. AANS — Differential.

Radiculopathy Versus CES

  • Radicular Pain / Sciatica: Radiating leg pain associated with root irritation; weakness is not required.
  • Radiculopathy: Nerve-root dysfunction producing sensory loss, weakness, or reflex change, often in a corresponding leg distribution.
  • CES: Sacral-root dysfunction affecting pelvic function / saddle sensation. Leg deficits may coexist but are not required; the syndrome is not defined simply by how many roots are compressed. Lavy 2022.
  • Urgency: New substantial or progressive motor weakness requires urgent imaging / spine assessment, even in one root distribution without bladder symptoms. “Not CES” does not mean “no important compression.” AANS — Herniated Disc.

What Moves The Needle?

  • Bladder: Altered urge / sensation, difficulty starting, weak stream, straining, incomplete emptying, or painless retention. Ask what changed—not only “any incontinence?”
  • Saddle / Sexual Function: New perineal or genital numbness, altered sensation when wiping, or new sexual dysfunction.
  • Bowel: New loss of awareness or control, especially with other sacral findings.
  • Legs: New substantial or progressive weakness, gait change, or multiple-root symptoms. Bilateral symptoms raise concern; asymmetry does not exclude CES.
  • Trajectory: Document the onset and progression of each deficit. A plausible urinary explanation does not override a concerning neurologic pattern. Lavy 2022.

Incomplete CES Or CES With Retention?

  • Incomplete CES: Neurogenic urinary difficulty while voluntary emptying remains possible. Altered sensation, weak stream, or straining may precede retention.
  • CES With Retention: Loss of voluntary bladder control with painless retention, sometimes causing overflow leakage. Wet clothing does not establish an empty bladder.
  • Do not wait for incomplete CES to progress to retention. A PVR number alone does not establish the stage. Todd 2022.

Examination / PVR

  • Neurologic Examination: Assess bilateral strength, sensation, reflexes, and gait when safe. Include relevant perineal sensation / sacral function; document actual findings and examination limitations.
  • Postvoid Residual — PVR: Measure promptly after voiding when feasible. Use the result with the urinary history and neurologic examination—not instead of them.
    • ≥200 mL: Increases concern but does not independently diagnose CES.
    • <200 mL: Does not exclude incomplete CES.
    • Journal Club — Katzouraki 2020: In a prospective suspected-CES cohort, PVR ≥200 mL had 94.1% sensitivity. Bladder scanning is an adjunct—not a stand-alone exclusion test. Study.
    • Journal Club — Todd 2022: A selected medicolegal series identified 13 definite incomplete-CES cases with PVR ≤200 mL, all requiring decompression. This demonstrates false reassurance, not the frequency in an unselected ED population. Study.
  • Rectal Tone: Normal tone does not exclude compression and should not be the sole basis for the MRI decision. Tabrah 2022.

MRI / Immediate Action

  • Suspected CES: Urgent MRI + neurosurgical / orthopedic spine consultation. Do not wait for retention, bilateral weakness, or the complete syndrome.
  • MRI Selection: Image the region supported by the examination; coordinate coverage and contrast for suspected tumor, infection, or more proximal disease. A sensory level or unexplained findings require assessment beyond an isolated lumbar root. A lumbar x-ray does not answer the compression question.
  • Confirmed Compressive CES: Urgent surgical assessment for decompression. A quoted 24–48-hour window is not permission to delay imaging, consultation, or transfer.
  • While Arranging Care: Repeat the examination. If MRI is unavailable, arrange urgent transfer or a specialist-directed alternative; an unexplained objective deficit requires reassessment of the level and neurologic differential. WFNS 2024 — International Consensus.

Cause-Specific Action

  • Disc-Related Compression: Urgent assessment for decompression; systemic steroids are not an established substitute. WFNS 2024.
  • Malignant Compression: Urgent MRI + spine / oncology consultation when compression is suspected. Progressive unexplained pain in a patient with cancer warrants assessment even without weakness.
    • Dexamethasone: Follow the cancer-specific pathway. MD Anderson uses 10 mg IV initially, then 16 mg PO daily in divided doses; subsequent route and taper follow the treating team's plan. This is not a generic steroid regimen for every compressive syndrome. MD Anderson 2025.
    • Suspected Undiagnosed Lymphoma: Obtain immediate oncology / hematology input on steroid timing. Do not reduce this to “possible lymphoma → no steroids,” particularly with neurologic compromise.
      • Guideline Qualification: MD Anderson cautions against empiric steroids in undiagnosed lymphoma. NICE recommends prompt dexamethasone for malignant cord compression with neurologic findings; its advice to seek hematology input before steroids for suspected lymphoma / myeloma specifically addresses patients without neurologic symptoms or signs. NICE — Corticosteroid Therapy.
  • Spinal Epidural Hematoma: Acute pain / neurologic change with bleeding or procedural risk → emergency MRI + spine consultation. Identify the anticoagulant and last dose. AANS — Causes.
    • Suspected / Confirmed Spinal Hematoma With Neurologic Compromise: Stop anticoagulation and urgently assess drug-specific reversal while arranging definitive spine care. This applies critical-site bleeding management—not empiric reversal for every anticoagulated patient with back pain. ACC — Anticoagulant-Related Bleeding.
  • Infection / Other Myelopathy: Suspected infection follows the Spinal Infection pathway. Persistent myelopathy without compression requires neurologic evaluation, including inflammatory causes such as transverse myelitis.

Spinal Epidural Abscess / Vertebral Infection

What Is It?

  • Spinal Epidural Abscess — SEA: Infection within the spinal canal, outside the dura. It can compress the cord or cauda equina and cause permanent neurologic injury.
  • Related Infection: Vertebral osteomyelitis involves bone; discitis involves the disc space. They may coexist with SEA but are not interchangeable diagnoses.
  • Source / Organisms: Bloodstream spread, extension from adjacent infection, or direct inoculation after a spinal procedure. S. aureus is the leading organism; resistant staphylococci and relevant gram-negative organisms affect empiric treatment. AANS — Spinal Infections.

What Moves The Needle?

  • Pain: New, persistent, or worsening focal spine pain. Repeat visits or a change from chronic pain warrants reassessment.
  • Infection Risk: Recent bacteremia / infection, injection drug use, indwelling vascular access, spinal injection / surgery, diabetes, renal disease, or immunocompromise.
  • Neurologic Change: Radicular pain, weakness, sensory change, gait impairment, or bladder / bowel dysfunction. Do not wait for paralysis or an orderly progression.
  • Absent Classic Features: Neither absence of fever nor absence of injection drug use excludes SEA.
    • Journal Club — Durant 2025: Among 457 patients with MRI-confirmed SEA, only 10% had spine pain + fever + neurologic symptoms; 71% had a potentially related visit before diagnosis. Reassess evolving presentations without turning every repeat visit into an automatic MRI indication. Study.

Diagnosis — Infection And Extent

  • High Suspicion / Neurologic Change: Obtain MRI and involve the spine team. ESR / CRP may support the assessment, but reassuring markers do not cancel a concerning presentation.
  • MRI: Spine MRI with and without IV contrast when feasible defines epidural infection, compression, and adjacent disease. Coordinate coverage when more extensive involvement is suspected. AANS — Imaging.
  • Laboratory: Obtain CBC, ESR / CRP, renal function, and two sets of blood cultures. A normal WBC does not exclude infection. Obtain samples alongside imaging / treatment rather than making the results a prerequisite. IDSA — Vertebral Infection.
  • ESR / CRP: Supporting tests—not a stand-alone rule-out strategy or a mandatory gate before MRI.
    • Journal Club — Davis 2011: Risk-based assessment and inflammatory markers improved diagnostic evaluation in a selected single-center population. The reported sensitivity is not a universal exclusion guarantee. Study.

Immediate Treatment / Surgical Assessment

  • Neurologic Deficit / Sepsis: Urgent spine consultation + empiric IV antibiotics. Obtain cultures promptly, but do not wait for laboratory results or biopsy in an unstable or neurologically worsening patient.
  • Empiric Antibiotics: Cover MRSA, streptococci, and relevant gram-negative organisms. Vancomycin + a third- or fourth-generation cephalosporin is a typical framework; select the agent and dose for renal function and resistance risk, then narrow to cultures.
  • Stable Native Vertebral Osteomyelitis: ID / spine teams may obtain microbiologic samples before antibiotics when hemodynamics and neurologic findings are stable. This is not a default instruction to delay SEA treatment. IDSA 2015.
  • Drainage / Decompression: Urgent operative assessment for neurologic compromise, significant compression / instability, or failed medical treatment. Nonoperative care requires specialist selection and close surveillance—not routine ED discharge. AANS — Treatment.
  • Reassessment: Repeat motor, sensory, gait, and sphincter findings. Worsening neurologic function requires immediate escalation even if fever or laboratory values improve. See Disposition.

Vertebral Fracture

  • Fracture Risk? Trauma or focal vertebral pain with osteoporosis, older age, or prolonged steroid exposure increases concern. Steroid exposure alone does not establish fracture. Han 2023.
  • Imaging: Use radiography / CT according to the injury and fracture risk. MRI addresses neurologic involvement or an unresolved occult injury; match the study to the question.
  • Neurologic Deficit / Suspected Instability: Spine consultation. A stable fracture still requires pain control, safe mobility, and a follow-up plan. ACR/RSNA — Imaging.

Visceral Cause?

Pyelonephritis

What Is It?

  • Kidney Infection: Infection of the collecting system and renal tissue, usually ascending from the lower urinary tract. Flank pain and systemic illness distinguish the clinical concern from isolated bladder symptoms. NIDDK — Pyelonephritis.
  • Upper Versus Lower UTI: Flank / CVA pain and systemic symptoms support upper-tract infection; isolated dysuria / frequency fits a lower-tract pattern. Either may coexist with obstruction.
  • Complicated UTI: IDSA includes pyelonephritis because infection extends beyond the bladder. The label alone does not mandate admission. IDSA 2025 — Classification.

What Moves The Needle?

  • Typical Pattern: Flank pain / CVA tenderness, fever / chills, or nausea / vomiting, with or without dysuria, urgency, or frequency. Absent lower urinary symptoms do not exclude pyelonephritis. EAU — Diagnosis.
  • Higher Risk: Hemodynamic instability, organ dysfunction, suspected stone / obstruction, renal impairment, immunocompromise, recent instrumentation, or a prior resistant organism. Inability to hydrate or tolerate therapy also changes the care setting.
  • Pregnancy + Suspected Pyelonephritis: OB consultation + initial inpatient treatment. Do not apply the ordinary outpatient pyelonephritis plan. ACOG — Pyelonephritis In Pregnancy.
  • Alternative Diagnosis? Midline spine pain / neurologic findings, atypical abdominal pain, or vascular concern requires assessment beyond the urine result.

UA / Culture / Blood Tests

  • UA: Interpret pyuria, bacteriuria, and nitrite with the symptoms and examination. A reassuring specimen does not dismiss suspected infection behind an obstruction.
  • Urine Culture: Obtain culture and susceptibility testing for suspected pyelonephritis, before antibiotics when feasible without delaying urgent treatment. EAU — Laboratory Diagnosis.
  • Bacteriuria Alone: Does not explain back pain or delirium by itself. Without urinary or systemic infection findings, assess alternatives. IDSA 2019.
  • WBC Casts: Support renal inflammation but are not specific for infection; interstitial nephritis can also produce them. ASPN — WBC Casts.
  • Blood Tests: Creatinine / electrolytes and CBC when clinically relevant; blood cultures / lactate for sepsis or significant systemic illness.

Imaging — Obstruction Or Complication?

  • Typical Low-Risk Presentation: Imaging is not required solely to confirm pyelonephritis. Order a study when the question is obstruction, complication, or another diagnosis.
  • Image Early: Suspected obstruction / stone, significant renal impairment, severe illness, or another complication risk.
  • Ultrasound: Assess hydronephrosis / obstruction.
  • CT Abdomen / Pelvis With IV Contrast: Evaluate renal infection complications, abscess, or an alternative diagnosis. This answers a different question from a noncontrast stone study. ACR/RSNA — Pyelonephritis.
  • Not Improving By 48–72 Hours? Review the culture, antibiotic activity, and diagnosis; assess for obstruction or abscess. Clinical deterioration warrants evaluation now—not after another 48–72 hours. EAU — Reassessment.

Antibiotics — Active Drug, Appropriate Route

  • Selection: Match severity, prior cultures, recent antibiotic exposure, local resistance, allergies, renal function, and interactions. Narrow when susceptibilities return.
  • Oral Therapy? Appropriate for a selected stable, nonpregnant patient who can tolerate an effective regimen and has no unresolved obstruction or major complication. Select a fluoroquinolone when appropriate and likely active, or TMP-SMX / a selected oral beta-lactam when supported by susceptibility and protocol.
  • Initial Parenteral Dose? Consider a long-acting agent such as ceftriaxone when the oral plan needs initial empiric coverage. An initial IV dose does not rescue an inactive oral course. EAU — Oral Treatment.
  • IV Therapy? Sepsis, inability to tolerate oral therapy, or another reason that an effective oral plan is unsuitable. Broaden according to severity and resistance risk; a prior resistant organism may make ceftriaxone inadequate. Pregnancy follows the separate inpatient pathway.
  • Duration — Nonpregnant Patients Improving On Effective Therapy: Count from the first effective dose.
    • Fluoroquinolone: 5–7 days.
    • Non-Fluoroquinolone: 7 days.
    • Individualize: Obstruction, abscess, suspected prostatitis, severe illness, or other excluded trial populations. Short-course oral beta-lactam data remain limited. IDSA 2025 — Duration.
  • Pregnancy: ACOG recommends initial inpatient care with parenteral antibiotics until clinical improvement and 14 days total treatment. Follow the obstetric plan rather than applying the general short-course durations above. ACOG.
  • Bladder-Only Regimens: Nitrofurantoin and single-dose oral fosfomycin are bladder-treatment regimens—not treatment for pyelonephritis. EAU — Pyelonephritis.

Complications / Reassessment

  • Infected Obstruction: Antibiotics + drainage. See Urgent Urologic Problems.
  • Abscess / Gas-Forming Infection: Appropriate imaging + early urology / ID assessment; source control may be necessary. Do not simply extend an ineffective prescription. ACR/RSNA — High-Risk Imaging.
  • Response: Recheck perfusion, pain, vomiting, oral tolerance, and renal function. Assign responsibility for culture review and treatment adjustment.
  • Outpatient Care? Selected nonpregnant patient: stable, tolerating effective therapy, no unresolved obstruction / major complication, and reliable reassessment. Otherwise observation / admission; pregnancy requires initial inpatient care. See Disposition.

Renal Colic / Ureteral Stone

What Is Causing The Pain?

  • Obstructed Ureter: A stone impedes urine flow and increases upstream pressure, producing flank pain / nausea. Stone location, obstruction, and symptoms must fit; an incidental renal stone does not automatically explain the pain.
  • Typical Pattern: Unilateral flank pain radiating toward the groin, often in waves, with nausea / vomiting. Distal symptoms may include urgency, frequency, or genital pain. NIDDK — Stone Symptoms.
  • ED Priorities: Is this actually a stone? Is there infection? Is kidney function threatened? Can the symptoms be controlled while passage or intervention is arranged?

What Moves The Needle?

  • Infection: Fever / chills or systemic illness with suspected obstruction changes the priority to urgent drainage assessment.
  • Kidney At Risk: Solitary functioning kidney, bilateral obstruction, anuria / oliguria, or worsening renal function.
  • Alternative Cause: Atypical pain, syncope, abdominal findings, or vascular risk → reassess AAA, dissection, GI, or pelvic disease. Hematuria does not settle the differential.
  • Uncontrolled Symptoms: Persistent pain / vomiting despite treatment may require intervention rather than another outpatient prescription. EAU — Acute Assessment.

UA / Renal Function / Imaging

  • UA: Assess hematuria and infection; culture when infection is suspected. Absence of hematuria does not exclude a stone, and one urine result does not establish infected obstruction.
  • Renal Function: Compare creatinine with baseline and assess urine output. Urgency depends on the functioning kidney and obstruction—not creatinine alone.
  • Ultrasound: Selected initial assessment for hydronephrosis; no visible stone does not exclude ureterolithiasis.
  • Noncontrast CT: Defines stone size, location, and obstruction. Obtain when the diagnosis is uncertain, complications are possible, or the result will change treatment; use a reduced-radiation protocol when appropriate.
  • Different Imaging Question? Suspected aortic disease or renal infection complications require the corresponding protocol—not automatic noncontrast stone CT.
  • No Immediate Imaging? Selected reassuring recurrent presentations with low complication risk and reliable follow-up.
    • Journal Club — Smith-Bindman 2014: Initial ultrasound reduced radiation without a significant increase in high-risk diagnoses with complications. Additional CT was allowed when needed; ultrasound-first does not mean ultrasound-only. Study.

Pain Control / Passage / Follow-Up

  • NSAID? First-line analgesia when renal, GI, bleeding, and cardiovascular risks permit. Add an antiemetic or rescue analgesia when needed; nonspecific back-pain prescribing results should not be applied directly to renal colic.
  • Fluids? Replace actual volume depletion. Forced hydration does not reliably expel the stone, and an isolated creatinine rise does not justify repeated fluid.
  • Tamsulosin? Consider for selected distal ureteral stones 5–10 mm suitable for conservative care; this is off-label use. Benefit is less persuasive for very small stones likely to pass.
    • Guidance Context: These selection criteria follow EAU guidance. This is a European recommendation—not an automatic prescription for every stone.
  • Follow-Up: Base timing on stone size / location, kidney function, and residual symptoms. Confirm passage and recovery; collect a passed stone for analysis when possible.
  • Return Immediately: Fever / rigors, reduced urine, worsening pain, or inability to tolerate fluids / medication. Infection or threatened kidney function ends the routine passage pathway. EAU — Treatment / Follow-Up.

Infected Obstruction / Urgent Urologic Problem

  • Infection Behind An Obstruction: The infected collecting system cannot drain adequately and may progress rapidly to sepsis—even with a small stone.
  • Immediate Action: Obtain cultures, start IV antibiotics, resuscitate as needed, and involve urology / IR urgently for ureteral stent or nephrostomy. Antibiotics alone do not relieve the obstruction.
  • Drain First: Defer definitive stone treatment until infection is controlled. Tamsulosin is not source control.
  • Urgent Intervention Without Infection? Anuria, obstruction threatening a solitary kidney, worsening renal function, or refractory pain / vomiting. Size informs treatment planning; it does not establish septic urgency. EAU — Obstructed Kidney.

GI / Pelvic Cause?

  • Abdominal Findings: Pain / tenderness, GI bleeding, or bowel symptoms → evaluate the abdomen rather than obtaining lumbar imaging alone.
  • Pelvic / Pregnancy Findings: Pelvic pain, vaginal / urethral bleeding or discharge, or possible pregnancy → pregnancy testing and targeted examination / imaging.
  • Use the Abdominal Pain / Pelvic Pain pathway when that syndrome better explains the presentation.

Mechanical Pain / Radiculopathy?

Radiculopathy — Does The Pattern Fit?

  • Root Pattern: Radiating leg pain with corresponding sensory, motor, or reflex findings supports a root syndrome. Disc herniation and spinal stenosis are possible causes.
  • Straight-Leg Raise: Reproduction of familiar radiating leg pain is more useful than isolated back discomfort. Crossed SLR reproduces affected-side symptoms when the opposite leg is raised.
  • Root Examination: Compare both legs and document the actual deficit—not simply “neurologically intact.”
Root Motor Check Reflex
L4 Knee extension Patellar
L5 Great-toe dorsiflexion / heel walking No dependable routine reflex
S1 Foot plantar flexion / toe walking Achilles
  • New Substantial OR Progressive Weakness: Urgent imaging + spine assessment, even if the findings fit one root. Assess for additional sacral / cord findings. See Radiculopathy Versus CES.
  • Pain Without Substantial / Progressive Weakness Or Other Unresolved Red Flags: Conservative care and reassessment. Elective intervention depends on concordant symptoms, imaging, disability, and treatment response—not pain severity or duration alone. AANS — Herniated Disc.

Nonspecific Mechanical Pain

  • Diagnosis: A reassuring assessment may support musculoskeletal pain without identifying one injured structure. “Lumbar strain” is not required to justify a reasonable conservative plan.
  • Testing: Usually unnecessary when serious spinal, vascular, or visceral disease is not suspected.
  • Activity: Continue usual activities / walking as tolerated; avoid prescribed bed rest. Persistent limitation warrants follow-up rather than a promised recovery date. VA/DoD 2022.
  • Other Patterns: Stenosis, spondylolisthesis, or inflammatory pain may require separate outpatient assessment when emergency findings are absent.

Analgesia — Improve Function

  • Goal: Improve pain enough for safe movement and a workable home plan. Choose treatment according to the likely cause and patient-specific risks—not an automatic medication combination.
  • NSAID? A short course when renal, GI, cardiovascular, and bleeding risks permit.
  • Acetaminophen? Do not present it as equally established first-line monotherapy for low back pain; VA/DoD suggests against its use for this indication. VA/DoD 2022 — Medications.
  • Muscle Relaxant? Consider selected short-term use, not an automatic addition. Discuss sedation and its effect on safe mobility and daily function.
    • Guideline Difference: ACP permits use for acute nonradicular pain; VA/DoD finds insufficient data for or against short-term use. ACP 2017 · VA/DoD 2022.
  • Opioid? Not routine for uncomplicated mechanical pain. Selected rescue requires reassessment of the diagnosis, alternatives, sedation, and follow-up.
    • Journal Club — OPAL 2023: An oxycodone/naloxone course did not improve six-week pain in acute nonspecific back / neck pain. This does not settle every immediate rescue-analgesia question. Study.
  • Combination Prescriptions: Avoid automatically adding a sedating muscle relaxant or opioid to an NSAID.
    • Journal Club — Friedman 2015: In acute nontraumatic, nonradicular ED back pain, adding cyclobenzaprine or oxycodone/acetaminophen to naproxen did not improve one-week function or pain. Study.

Sciatica Medications

  • Systemic Steroid? Not the default for sciatica. This decision is separate from dexamethasone for malignant compression.
    • Journal Club — Goldberg 2015: Prednisone produced modest functional improvement without improved pain in disc-related radiculopathy, with more adverse effects. Study.
  • Gabapentinoid? Radicular pain is not an automatic indication.
    • Journal Club — Mathieson 2017: Pregabalin did not significantly improve leg pain or other measured outcomes in sciatica and caused more adverse events. Study.

Reassess / Disposition

What Changed After Treatment?

  • Repeat Examination: Recheck strength, gait, evolving bladder / saddle symptoms, systemic findings, and symptom control. Compare with the initial examination and baseline.
  • Function: Confirm oral tolerance, safe mobility, and ability to manage at home.
  • Unresolved Concern: Pain relief does not exclude a serious cause. Document the findings and suspected mechanism—not merely “no red flags.”
  • Definitive Care: Necessary decompression, vascular intervention, or urinary drainage must not wait for a routine inpatient bed. Arrange the appropriate specialist / transfer pathway.

Discharge

  • Overall Assessment: No unresolved neurologic, vascular, infectious, or obstructive concern; symptoms manageable and mobility / home care safe.
  • Mechanical / Radicular Pain: No substantial or progressive weakness or other unresolved serious concern. Provide activity and medication instructions, with follow-up for persistent symptoms or functional limitation.
  • Pyelonephritis: Selected nonpregnant patient, stable and tolerating an effective treatment plan, without unresolved obstruction / complication. Assign a clinician to review the culture.
  • Renal Colic: Symptoms controlled, kidney function not threatened, and infection concern addressed. Arrange reliable passage / urology follow-up.
  • Return Immediately: New or worsening weakness, difficulty urinating, bladder / bowel change, saddle numbness, fever / systemic illness, or worsening pain with new abdominal / vascular symptoms.

Monitored Admission

  • CES / Spinal Infection: Required MRI, consultation, serial examination, or treatment. Low PVR or temporary pain relief does not replace that assessment.
  • Urinary Disease: Infected obstruction, important renal dysfunction, or uncontrolled pain / vomiting requiring inpatient care. Pregnancy + suspected pyelonephritis → OB consultation + initial inpatient treatment.
  • Function / Other Risk: Fracture, objective weakness, unsafe mobility, or symptoms that remain unmanageable despite treatment. Observation is appropriate only where necessary evaluation and escalation are available.

ICU Admission

  • Physiology / Support: Shock, organ-support requirements, or severe systemic illness requiring intensive care.
  • Deterioration / Complications: Neurologic deterioration or a vascular / spinal complication requiring intensive monitoring or support.
  • The care setting follows physiology and required care. Suspected CES alone does not mandate ICU instead of urgent MRI / surgical assessment.

In The Pit

  • Abrupt severe back / abdominal pain + syncope, shock, or vascular findings: Assess AAA / dissection; resuscitate and involve the vascular / aortic team early
  • New substantial or progressive weakness, bladder dysfunction, or saddle sensory change: Urgent MRI + spine consultation. Low PVR or normal rectal tone does not clear the patient
  • Concerning spine pain + infection risk: Assess for SEA / vertebral infection. High suspicion → MRI; neurologic deficit or sepsis → urgent spine consultation + IV antibiotics
  • Trauma or focal vertebral pain + fracture risk: Image for fracture; neurologic deficit or suspected instability → spine consultation
  • Flank pain / urinary findings: Assess pyelonephritis, stone, and obstruction. Infected obstruction → IV antibiotics + urgent drainage
    • Pregnancy + suspected pyelonephritis → OB consultation + initial inpatient treatment
  • Reassuring mechanical / radicular pain without substantial or progressive weakness or other unresolved red flags: Activity, appropriate analgesia, and follow-up. Immediate imaging is usually unnecessary
  • Before discharge: Repeat strength / gait, reassess bladder or saddle symptoms, confirm safe function and the home plan, and explain specific return precautions. See Disposition

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