St Emlyn’s Lesson Plans
Back pain: recognising the dangerous exception
Discuss spinal and vascular causes of back pain, the limits of examination and advice for uncomplicated pain.
New to Emergency Medicine / Induction / Early-career Emergency Medicine · 45-minute session
For learners
Before: Allow about 16 minutes in total.
When we meet: We will discuss possible cauda equina syndrome, a vascular emergency and how the advice differs for uncomplicated back pain.
Practise: use the practice card with a partner.
For facilitators
Send: the learner preparation link before teaching.
Bring: A pathway printout, body diagram and blank discharge advice sheet.
Run: 45-minute session plan · 30-minute option
Practise: use the card for observed practice and feedback. Allow time for both turns, or arrange a follow-on practice session.
Before the session
If you are attending this session, complete the core preparation below before you come. Allow about 16 minutes in total.
Core preparation
NICE NG59: Low back pain and sciatica · About 8 minutes
Read the assessment and pharmacological sections of the low-back-pain guideline. Note where recommendations differ for sciatica.
https://www.nice.org.uk/guidance/ng59/chapter/recommendations
NICE NG156: Abdominal aortic aneurysm · About 5 minutes
Read NG156’s recommendations on identifying symptomatic or ruptured AAA and using bedside ultrasound. Note what to do if the scan is unavailable or inconclusive.
https://www.nice.org.uk/guidance/ng156
Think about (allow 3 minutes): Which question about new bladder or saddle-sensory symptoms would you ask directly?
Picture the scene
A 76-year-old has sudden back pain after lifting luggage. They want analgesia and a quick discharge so they can catch a flight.
By the end of the session
- Identify features prompting urgent assessment for spinal or non-spinal causes.
- Explain the limits of examination and when emergency imaging is needed.
- Make an evidence-aligned treatment and safety-net plan for uncomplicated pain.
After the session
- Practise asking a sensitive neurological question without euphemism.
- Check whether your department’s old back-pain leaflet still recommends ineffective medicines.
Facilitator guide
Send learners the preparation link several days before teaching. Allow about 16 minutes in total.
Before learners arrive
- Confirm the emergency MRI/spinal and vascular pathways, including out-of-hours arrangements.
- Bring current patient back-pain advice and the local prescribing formulary.
Equipment: A pathway printout, body diagram and blank discharge advice sheet.
Setup: Pairs practise asking about bladder and saddle-sensory changes in plain language. Then compare the spinal and vascular cases, tracing each plan through to the relevant local service.
If the preparation has not been completed
Replace the first-impression and focused-question activities (12 minutes). Read the linked assessment and medication sections for eight minutes, then use four minutes to practise asking about bladder and saddle-sensory changes. Have the local emergency MRI and vascular contact sheet available for the cases. For the 30-minute version, use the five-minute focused-history slot: three minutes with the assessment guidance and two to practise the questions.
Suggested session plan
- 0–5 min — Challenge the first impression. Ask how much the lifting story should change concern.
- 5–12 min — Prepare focused questions. Pairs practise asking bladder and saddle-sensory questions plainly.
- 12–34 min — Two cases. Follow the spinal and vascular branches to an actual local contact.
- 34–40 min — Contrast uncomplicated pain. Agree activity, proportionate medication and specific return advice.
- 40–45 min — Choose a follow-up action. Choose one change to history taking or documentation.
Start the discussion
Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.
Cases and discussion
Use these cases, or invite an anonymised case from the group that addresses the same questions.
Back pain with new bladder symptoms
A 38-year-old has worsening back pain and leg pain. When asked directly, they describe difficulty initiating urination and altered sensation when wiping.
Add this information as the discussion develops:
- Leg strength is near normal. A colleague suggests reassurance because the examination is not dramatic.
Ask the group:
- Which details need to be clarified and documented?
- What can the examination exclude?
- How does urgent MRI happen locally?
Discussion notes
Points to draw out:
- Ask clearly about new bladder, bowel, sexual and saddle-sensory changes and leg neurological symptoms; establish timing and progression.
- Normal strength, a reassuring rectal examination or one bladder measurement cannot safely exclude cauda equina syndrome in a concerning clinical presentation.
- Escalate urgently and follow the current emergency MRI/spinal pathway; examination and bladder assessment are adjuncts, not reasons to delay indicated imaging.
Common misconceptions:
- Waiting for complete urinary retention or dense bilateral weakness.
- Using a checklist of red flags as a validated rule-out test.
For a more experienced group: Discuss escalation if local MRI is unavailable out of hours.
The mechanism is not the diagnosis
The 76-year-old with lifting-related back pain now mentions a brief collapse. They have hypertension and look pale.
Add this information as the discussion develops:
- Bedside aortic ultrasound is technically limited.
Ask the group:
- What diagnosis changes the location and urgency of care?
- What does an inconclusive scan mean?
- How will you prevent the travel deadline from driving the decision?
Discussion notes
Points to draw out:
- Consider symptomatic or ruptured AAA and other serious causes; obtain senior help and monitored assessment.
- NICE recommends immediate bedside aortic ultrasound when AAA is suspected and immediate vascular discussion if positive, unavailable or non-diagnostic while suspicion remains.
- Keep the patient involved, explain the concern and arrange appropriate resuscitation and specialist care without treating a normal-looking abdomen as exclusion.
Common misconceptions:
- Accepting lifting as proof of a muscular diagnosis.
- Treating an incomplete ultrasound as negative.
For a more experienced group: Contrast with a third patient with uncomplicated mechanical pain and no concerning features; agree activity and medication advice.
Important clinical points
- NICE NG59 advises against paracetamol alone for low back pain and against routine opioids; NSAID decisions require individual risk assessment.
- Do not offer benzodiazepines, gabapentinoids or oral corticosteroids for sciatica under NG59.
- New bladder/bowel dysfunction, altered saddle sensation or progressive weakness needs urgent reassessment; provide explicit return instructions.
Practise with a partner
Use the card to rehearse the skill together. One learner performs. One learner checks the key steps and gives feedback. Then swap roles.
Lower limb neurological examination · FRCEM
Practise with a partnerRead the observer setup and allow time for both turns. Use the card alongside the lesson activity or in a follow-on practice session.
Closing the session
Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.
- Why is a normal neurological examination insufficient in case one?
- When is a bedside aortic scan unhelpfully reassuring?
- What would you advise a patient with uncomplicated pain to do next?
Key teaching points:
- A lifting injury does not exclude a serious spinal or vascular cause of pain.
- A reassuring examination alone cannot exclude cauda equina syndrome.
- For uncomplicated back pain, give practical activity and treatment advice; routine imaging is usually unnecessary.
Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.
Adapting the discussion
Uncertainty and local practice
Red-flag symptoms are imperfect. Use clinical judgement, progression and the current emergency pathway rather than a single sign or cut-off.
If the discussion drifts
What dangerous explanation still fits, and what would safely resolve that concern?
For a more experienced group
Add infection, cancer, immunosuppression or anticoagulation and ask how they change the investigation threshold.
A 30-minute version
30 minutes: focused history 5; spinal case 10; vascular case 8; uncomplicated contrast 4; reflection 3. Omit the longer documentation exercise.
Evidence and guidance
- NICE NG59: Low back pain and sciatica — Current recommendations distinguish low back pain from sciatica and limit ineffective or harmful medication.https://www.nice.org.uk/guidance/ng59/chapter/recommendations
- RCEM: Clinical Standards and Guidance — Includes the 2024 cauda equina statement responding to the GIRFT pathway. Review the current local emergency MRI pathway.https://rcem.ac.uk/clinical-standards-and-guidance/
- NICE NG156: Abdominal aortic aneurysm — Recognition and urgent vascular assessment of suspected rupture.https://www.nice.org.uk/guidance/ng156
Suggested curriculum links
RCEM 2021 curriculum (2025 update): SLO1 Care for physiologically stable adults with acute presentations
Safe assessment, differential diagnosis and disposition.
RCEM 2021 curriculum (2025 update): SLO3 Resuscitate and stabilise adults
Recognition, prioritisation and team escalation.
Check these links against the learner’s stage and programme. Attendance at a teaching session does not establish competence.
First published 2020-06-08 · Iain Beardsell.