St Emlyn’s Lesson Plans
Assessing acute back pain
Distinguish an urgent neurological or vascular concern from uncomplicated back pain and give a useful recovery plan.
Medical Students · 45-minute session
For learners
Before: Allow about 12 minutes in total.
When we meet: We will assess possible cauda equina syndrome and a vascular cause of back pain, then contrast these with uncomplicated mechanical pain.
Practise: use the practice card with a partner.
For facilitators
Send: the learner preparation link before teaching.
Bring: Pathways and an empty 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 12 minutes in total.
Core preparation
NICE NG59 low back pain and sciatica · About 7 minutes
Read the alternative-diagnosis advice (1.1.1), imaging recommendations (1.1.4–1.1.6), self-management advice (1.2.1), and the two short pharmacological-management sections for sciatica and low back pain. Focus on where their advice differs.
https://www.nice.org.uk/guidance/ng59/chapter/recommendations
NICE NG156 symptomatic/ruptured AAA · About 3 minutes
Read only the section “Identifying symptomatic or ruptured abdominal aortic aneurysms”. Focus on recognition, immediate bedside ultrasound and the action when ultrasound is unavailable or inconclusive.
https://www.nice.org.uk/guidance/ng156/chapter/Recommendations
Think about (allow 2 minutes): What would new difficulty passing urine change in your assessment of a person with back pain who can still walk?
Picture the scene
A 76-year-old develops sudden back pain while lifting luggage. They want analgesia quickly so they can catch a flight; only later do they mention briefly losing consciousness.
By the end of the session
- Ask specific questions that identify possible neurological or vascular emergencies.
- Explain why a normal isolated examination finding does not exclude cauda equina syndrome.
- Propose proportionate management and safety-netting for uncomplicated acute back pain.
After the session
- Practise asking about bladder and saddle symptoms clearly and respectfully before your next back-pain history.
Facilitator guide
Send learners the preparation link several days before teaching. Allow about 12 minutes in total.
Before learners arrive
- Bring the local urgent MRI/cauda-equina and vascular pathways.
- Review the local back-pain leaflet and analgesic formulary for NG59 consistency.
Equipment: Pathways and an empty discharge-advice sheet.
Setup: Pairs identify a decision-changing detail; then one pair explains a recovery plan for the uncomplicated contrast.
If the preparation has not been completed
Replace the five-minute “Establish the essentials” slot. Write “bladder and bowel change, sensation, systemic illness, vascular concern” on a board. Pairs spend two minutes turning these into specific questions, two applying them to the case histories, and one checking the urgent MRI and vascular contacts. The facilitator brings the local routes; a normal single finding must not become a rule-out test.
Suggested session plan
- 0–5 min — Explore. Ask what the late disclosure of collapse changes.
- 5–10 min — Establish the essentials. Turn vague ‘red flags’ into specific questions.
- 10–32 min — Discuss & Apply. Spend 10 minutes per urgent case and 2 on the uncomplicated contrast.
- 32–40 min — Consolidate. Ask pairs to state precise bladder-history questions, explain the inconclusive aortic scan and give advice for uncomplicated back pain.
- 40–45 min — Reflect & Transfer. Allow a brief paired rehearsal of bladder and saddle-sensation questions before learners use them on placement.
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 a new bladder symptom
A 38-year-old has worsening back pain and pain down one leg. On direct enquiry they report altered bladder sensation and difficulty starting urination.
Add this information as the discussion develops:
- They can walk and limb power appears normal.
- A colleague says a normal rectal examination or a low bladder volume would make urgent MRI unnecessary.
Ask the group:
- What needs clarification using the patient’s words?
- Which findings cannot safely dismiss the concern?
- What should the student do now?
Discussion notes
Points to draw out:
- Ask about new urinary sensation/function, bowel and sexual symptoms, saddle sensation and evolving leg symptoms; document onset and changes.
- Concern for cauda equina syndrome needs urgent senior assessment and the local emergency MRI/spinal pathway.
- No single normal finding, including leg strength, anal tone or bladder assessment, is sufficient to exclude the diagnosis. Do not wait for complete retention or every classic feature.
- Examinations should have a purpose, consent and appropriate chaperoning; avoid performing an intimate examination as a ritual rule-out.
Common misconceptions:
- Recording ‘red flags negative’ instead of the actual questions and answers.
- Assuming unilateral leg symptoms exclude a central neurological problem.
For a more experienced group: Discuss who requests urgent MRI out of hours and what happens if it is unavailable locally.
Luggage, back pain and a faint
The 76-year-old looks comfortable after lying down but had abrupt severe back pain followed by collapse. There is a vascular history.
Add this information as the discussion develops:
- Observations are borderline rather than profoundly abnormal.
- A bedside aortic scan by an appropriately trained clinician is nondiagnostic.
Ask the group:
- Why should the ‘lifting injury’ story not settle the diagnosis?
- What are the urgent location, review and referral decisions?
- Does a nondiagnostic scan end the assessment?
Discussion notes
Points to draw out:
- Consider symptomatic or ruptured AAA and other dangerous causes; move to appropriate monitoring and seek immediate senior assessment.
- NICE recommends immediate bedside aortic ultrasound when AAA is suspected and immediate discussion with the regional vascular service if it shows AAA, is unavailable or is nondiagnostic while suspicion persists.
- Do not delay referral for a perfect history or use the patient’s wish to leave as evidence of low risk.
Common misconceptions:
- Assuming a person in a minor-injury area cannot have a vascular emergency.
- Using absence of a palpable mass to exclude AAA.
For a more experienced group: Contrast with a 45-year-old who has uncomplicated mechanical pain, normal neurological assessment and no concerning features: what would useful conservative care and return advice contain?
Important clinical points
- Do not use a normal PR examination, strength or bladder measurement alone to exclude cauda equina syndrome.
- For uncomplicated low back pain, NICE advises against paracetamol alone and routine opioids; NSAIDs require individual risk assessment.
- Do not offer benzodiazepines, gabapentinoids or oral steroids for sciatica under NG59.
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 neurology · MLA
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.
- Replace ‘no bladder red flags’ with two precise questions.
- Explain why a nondiagnostic aortic scan is not a discharge result.
- Give an activity and return-advice plan for uncomplicated pain.
Key teaching points:
- Ask clearly about new neurological, bladder and bowel symptoms.
- Consider vascular and other causes outside the spine.
- For uncomplicated pain, discuss activity, symptom relief and when to seek review.
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 flags support judgement but are not a perfect screening test. The threshold for urgent imaging requires a senior assessment of the whole presentation.
If the discussion drifts
Which detail changes the safe next step for this person?
For a more experienced group
Explore how severe functional limitation, fracture risk, infection or malignancy alters assessment without ordering imaging for everyone.
A 30-minute version
30 minutes: opening 3, questions 5, two cases 15, consolidation 5, reflection 2.
Evidence and guidance
- NICE NG59 — Assessment, imaging and treatment.https://www.nice.org.uk/guidance/ng59/chapter/recommendations
- NICE NG156 — Symptomatic/ruptured AAA.https://www.nice.org.uk/guidance/ng156/chapter/Recommendations
- RCEM clinical guidance index — Lists the 2024 response to the GIRFT cauda-equina pathway; use local emergency MRI arrangements.https://rcem.ac.uk/clinical-standards-and-guidance/
Suggested curriculum links
GMC Outcomes for graduates / MLA 2026: Back pain; neurological and vascular emergencies
Learners recognise important exceptions and avoid inappropriate routine investigation.
Check these links against the learner’s stage and programme. Attendance at a teaching session does not establish competence.
First published 2020-09-22 · Iain Beardsell.