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