Acute onset with associated activity suggests mechanical process
Acute onset without trigger, particularly if severe pain may suggest vascular process
Progressive onset without trigger suggests non-mechanical process (i.e. malignancy)
Aggravating/Alleviating Factors
Worsening with cough/valsalva suggests herniated disk
Relief with flexion associated with spinal stenosis
Location/Radiation
Radicular pain typically extends below knee, associated with nerve root involvement
Radiation to/from chest or abdomen suggests visceral source
Flank location suggests retroperitoneal source
History/Associated Symptoms
Fever
Medications (particularly anti-coagulants)
Hematuria
Malignancy
IVDA
Vascular disease
Key Physical Findings
Abnormal vital signs
Fever: abscess, osteomyelitis, discitis
Hypertension: dissection
Shock: AAA
Localize point of greatest tenderness
Examine abdomen for pulsatile mass
Perform thorough neurological examination including rectal tone and perianal sensation
Positive straight leg raise associated with sciatic nerve root irritation and is sensitive (but not specific) for disk disease.
References
Mahoney, B. (2013). Back Pain. In Rosen’s Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 278-284). Elsevier Health Sciences.
