MEDICINE AND OTHER SPECIALTIES
Acute back pain and
cauda equina
Oliver Seyfried
Abstract
Acute low back pain is a very common presentation in primary care. In
the vast majority of patients, it is benign and will run an indolent
course. There are multiple causes, of which most are structural.
Back pain can be isolated as well as present with sciatica, which is
usually unilateral. Provided there are no signs or symptoms that
might suggest a more sinister cause, further investigation is rarely
helpful, and patients will improve with time and simple analgesia. Ed-
ucation is important to alter abnormal health beliefs, and a multidisci-
plinary and biopsychosocial approach is ideal. Where pain is severe
and a more serious cause cannot be ruled out, rapid onward referral
should be undertaken, especially in regard to cauda equina syndrome.
Keywords Acute back pain; evaluation; lumbar radiculopathy;
management; MRCP; simple back pain; vertebral wedge fracture
Introduction
General practice, spinal surgery, pain medicine and obstetrics are
full of patients with back pain. The evolutionary advantage of
walking upright has had its advantages, in terms of carrying
items and increasing dexterity, but has put much pressure on the
spine, resulting in back and neck pain. Female individuals are
further disadvantaged as the narrower pelvis needed for efficient
locomotion results in cephalopelvic disproportion in regard to
delivering a large fetal head.
Lower back pain (lumbago) is a practically universal affliction
that varies significantly in its intensity, longevity, frequency and
effect on function. It usually causes problems after reproductive
age has been attained and therefore has a reduced evolutionary
pressure. As with many medical issues, the burden that back
pain places on health services is a result of life expectancy
increasing worldwide, from age 31 years in 1900 to 71.5 in 2014.
The International Association for the Study of Pain defines
pain as ‘an unpleasant sensory and emotional experience asso-
ciated with actual or potential tissue damage, or described in
terms of such damage’. Acute lower back pain is not a disease
but a collection of symptoms, and is defined (somewhat arbi-
trarily) as back pain that lasts <6 weeks. The separation of lower
back pain into acute and chronic should probably be reviewed to
consider it as a chronic condition with a chaotic nature of
recurrence and recovery.
Lower back pain is the second most common complaint for
which patients seek medical advice after colds and flu. It has
Oliver Seyfried MB BS FRCA FFPMRCA is a Consultant in Pain Medicine
and Anaesthesia at St George’s University Hospital NHS Trust,
London, UK. Competing interests: none declared.
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Key points
C Acute back pain has a favourable prognosis
C There is recurrence within a year in 40% of patients
C Diagnostic triage focuses on excluding specific pathology
C Patient-centred active management has the best outcome
C Surgery is used to cure sciatica and reduce the chance of
neurological compromise
been estimated that 31 million days of work were lost because of
it in 2013, with a potential cost of £14 billion. With regards to the
healthcare sector, in 1998 the direct healthcare costs were esti-
mated to be £251 million to the UK National Health Service
alone.1
The reason medical advice is sought so often is that the effects
of lower back pain can be profound, influencing all activities of
daily living including work. Inability to work increases social
exclusion and increases reliance on state handouts. It alters our
view of self, and often shifts our locus of control, particularly in
individuals working in physical jobs, and especially in those who
are educationally disadvantaged. It also affects those around the
patient, and the family or relationship dynamic is altered for the
worse.
The challenges
 Back pain can have multiple aetiologies, and patients’
health beliefs are integral to its course and management.
 Back pain is often recurrent and may follow different
paths: persistent mild, recovering, severe chronic and
fluctuating.2
 There are multiple treatment options that are often
underpinned by poor or no evidence, although the situa-
tion is improving with recent relevant randomized
controlled trials and systematic reviews.
 It is hard to recognize those at risk of chronicity.
 A further challenge is detecting individuals with serious
spinal pathology.
Pathophysiology
Tissues within the back that can cause or contribute to pain
include bone, muscle, ligaments, discs and nerves. They are not
mutually exclusive: for example, an extruded disc can simulta-
neously irritate nervous and muscular structures. Figure 1 shows
the structures around the lumbosacral spine.
Bone
Bony causes include fractures of all types; excluding moderate
and major trauma, the two most common are wedge fractures,
and pars interarticularis fractures which allow spondylolisthesis
to occur. Wedge fractures tend to occur in the thoracic spine
(because of its resistance to hyperflexion), albeit not exclusively.
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 MEDICINE AND OTHER SPECIALTIES
Figure 1 Lumbosacral anatomy. source: Complete Anatomy -www.3d4medical.com.
They need onward referral if adjacent vertebrae are affected,
there is a >50% loss of anterior height or it is suspected that
retropulsed fragments have entered the spinal canal. Although
the bones are frequently osteoporotic, pathological fracture and
bone disease such as osteomalacia, Paget’s disease or renal
osteodystrophy should be considered.
Spondylolisthesis (e.g. the hangman’s fracture, a colloquial
term for disruption of C2 due to a hyperextension injury). In the
lumbar spine it can be anterior or posterior, although the former
is prevalent. Aside from the pain it generates, the spinal canal
can be narrowed. The causes are degenerative, traumatic, path-
ological or iatrogenic, and congenital spinal anomalies. Pars
interarticularis defects are the most common cause and pre-
dominate in sportspeople. Diagnosis is often incidental because
of its non-specific presentation and chronic nature (Figure 2).
Ligaments and muscle
Sprains are common and often temporally related to back loading
or torsion. They frequently recur. The structure of the back is
complex (Figure 1) but robust. However, with pregnancy,
obesity, heavy lifting (at work and play) and the British public’s
Figure 2 Pars interarticularis fracture. source: Complete Anatomy
-www.3d4medical.com
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avoidance of pilates, the incidence of soft tissue damage is high.
The path to recovery is usually rapid, but the development of
chronicity remains a problem.
Damage to the muscles and ligaments leads to pain felt at the
site of damage and can be central or unilateral. Sacroiliac strain is
often unilateral and extends to the buttock and back of the leg.
Coccydynia occurs after mild to moderate trauma, including
childbirth, and is a common presentation at general practitioner
surgeries. It occurs more commonly in women because of the
coccyx’s increased vulnerability between more widely spaced
ischial tuberosities.
Discs
The discs weaken throughout life, with gradual loss of integrity
(reduced synthesis of proteoglycan matrix) of the annulus
fibrosus and associated dehydration (noticeable on T2-weighted
magnetic resonance imaging (MRI)) because of loss of nucleus
pulposus. Fissuring in the annulus fibrosus allows the nucleus
pulposus to herniate, irritating and compressing nearby struc-
tures. Contact of a paracentral disc with a nerve root leads to
sciatica and, if the root is compressed, paraesthesia and motor
effects can occur; however, these tend to be noticed only when
the pain subsides. Central herniation can lead to canal stenosis
and cause bilateral symptoms including neurogenic claudication
(Figure 3).
Nerves
Nervous pain can also be secondary to neuropraxia following
childbirth, or a resolved disc herniation. Nerve sheath tumours
or direct infiltration or pressure effects of pelvic tumours should
be borne in mind if the pain worsens on lying flat. In my clinical
experience, Tarlov cysts are those that form in the peri-neural
sheath of the dorsal root ganglion (usually at S1eS5) and
although initially thought to be asymptomatic it is clear that they
cause radicular pain in a number of patients.
It is thought that the disc itself can generate pain because of
chronic neovascularization and the spread of sensory nerve fi-
bres as far as the nucleus pulposus.3 These fibres can be sensi-
tized by continuing exposure to inflammatory mediators,
creating a picture of wind-up (a perceived increase in pain in-
tensity associated with repeated activation of peripheral
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 MEDICINE AND OTHER SPECIALTIES

Figure 3 Gross anatomy of the L5 vertebra and associated discs. source: Complete Anatomy
-www.3d4medical.com

neurones) and chronicity. Discal pain becomes less of an issue as Examination

people age because of reduced disc volume and a lower volume
of the nucleus pulposus that can herniate. In elderly individuals,
problems tend to arise from bony remodelling in the spine.
Loss of disc height places increased stress on the interver-
tebral facet joints and alters the back’s mechanics. Facet joint
arthropathy then occurs. Pain is felt in the low back and can
radiate to the groin and hip, and down the back of the leg to the
knee; it worsens on lateral flexion or retroflexion. Pain referred
to the back can arise from all systems within the trunk
(Table 1).
Inspection: Observe the patient from anterior, posterior and
lateral viewpoints whilst they are standing, sitting and walking.
Looking for changes in spinal curvature, muscular atrophy, skin
changes such as erythema ab igne (once known as ‘fireside
tartan’) or abnormal hair growth. Leg length discrepancy is
common and of dubious clinical significance.
Causes of referred pain
Location Cause

Clinical approach to acute back pain Renal system Stones, tumour, infection, hydronephrosis
Oesophagus Oesophagitis, hiatus hernia, tumour
History
Stomach and Peptic ulcer, tumour
Most causes of back pain can readily be diagnosed from a simple
duodenum
history and examination, and, importantly, the signs and symp-
Pancreas Pancreatitis, pancreatic cancer
toms of serious spinal pathology can be elicited or excluded.
Gallbladder Cholecystitis
‘SOCRATES’ is a useful acronym to use to investigate the pain
Aorta Aneurysm, peri-aortitis
(Table 2).
Bowel Diverticulitis, abscess, tumour
The flag system (Figure 4) is used to assess the potential
Ovary Tumour, cyst
severity of the pain, as well as to elicit psychosocial prognostic
Uterus Pelvic infection, tumour, dysmenorrhoea
factors for the development of chronicity after the onset of me-
chanical pain. Table 1

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 MEDICINE AND OTHER SPECIALTIES

 lateral flexion of 15e20

The SOCRATES acronym  rotation with a fixed pelvis of 3e18 .
Site Identify the focus
Onset Sudden, gradual, progressive, regressive Isometric muscle testing: this examination grades the strength
Character Somatic, neuropathic, visceral, mixed of a chosen muscle group whilst the muscles are in an initial
Radiation Sciatica below the knee, mechanical to the contracted state. It is time-consuming to do properly or well, is
knee but not below examiner dependent and best done by specialist services such as
Associations Early morning stiffness, improves with lying physiotherapy.
flat, worsens with sitting
Time course Pattern throughout the day or week Palpation: palpate the midline, checking for bony tenderness or
Exacerbating and Heat, massage, analgesia, Valsalva manoeuvre deformity; crush fractures can often be elicited this way. From
relieving factors here, moving laterally, muscular tenderness can be assessed.
Severity Numerical rating scale, pain diary Any correlation with pain from deep structures is difficult;
moderate pain often comes from spasm of the superficial
Table 2 musculature, whereas severe superficial pain is often exacer-
bated by nervous system wind up.
The sacroiliac joints, hamstring insertions, iliotibial bands and
Motion testing: active and gentle passive motion of the lumbar
piriformis (piriformis syndrome is overdiagnosed) can be iden-
spine should be assessed:
tified by asking the patient to lie prone. Lying the patient supine
 forward flexion of 40e60
allows examination of the anterior superior iliac spines, pubic
 extension of 20e35
symphysis and abdomen.

Flag System to assess the severity of potential back pain

Red Orange Yellow Blue Black

These are medical These are serious These Perception of Actual work
issues that must be psychiatric illnesses psychobehavioural occupation is to do conditions.
diagnosed early and that will prevent issues can be with the patient’s
not missed. effective pain addressed by certain work status and
management. members of your pain how they perceive
management team. their occupation.

Admit or refer to the Refer to psychiatrist Refer for

appropriate medical immediately. multidisciplinary
specialist pain management.
immediately.

Cancer Major personality Maladaptive behaviours Not working Poor work conditions
Infection disorder Maladaptive cognition Fear of re-injury Manual work
Fracture Substance abuse or beliefs Poor work satisfaction Unsociable hours
disorder Poor coping strategies
Cauda equina Work-related stress
Post-traumatic Pain catastrophizing
Neurology stress disorder
Structural deformity High levels of distress
Ischaemia High external locus
Psychosis of control
HIV/IVDU
Fear avoidance
Acutely unwell or
concurrent medical Anxiety/depression
problem Family reinforcement
Organic pathology Secondary pain
Over-solicitous spouse
Litigation
Compensation

IVDU, intravenous drug user.

Figure 4

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 MEDICINE AND OTHER SPECIALTIES
Neurological examination: a passive straight leg raise is positive
if there is an onset of sciatica or unilateral back buttock pain at
<70 of raise. It is caused by a loss of sciatic nerve root neural
glide secondary to scarring or frank nerve root entrapment in the
acute setting. This finding can be confirmed by worsening of the
symptoms at an angle 10 lower than this while passively dor-
siflexing the ankle.
The slump and femoral nerve traction tests are less specific
and unnecessary. The slump test involves a seated patient with
neutral spine slumping forward. This may reproduce sciatic pain
if there is no neural glide due to dural tethering being present.
Femoral nerve traction test involves passive extension of the hip
whilst the patient lies in the lateral position again looking for
reproduction or worsening of symptoms.
Full neurological examination of the lower limbs should be
undertaken looking at the tone, power, reflexes and coordina-
tion. L5 or S1 weakness can also be quickly identified by asking
the patient to stand on tiptoes and then walk on their heels.
Joint examination: facet pain increases with extension of the
lumbar spine, and the FABER test (Flexion, Abduction and
External Rotation) of the hip might help identify pain arising
from the sacroiliac joint as force is transmitted through the femur
and a fully externally rotated hip to that joint.
Further investigations to consider
Investigations are less important than a thorough history and
examination, but can often reassure both patient and physician.
According to recent National Institute for Health and Care
Excellence guidelines, routine imaging should not be offered in a
non-specialist setting. X-rays are unhelpful given the more
modern imaging techniques available. Investigations that can be
considered are:
 MRI in severe subacute pain, especially if motor effects and
red flags are present
 full blood count
 erythrocyte sedimentation rate and C-reactive protein
 markers of bone disease
 prostate-specific antigen.
Management3
Acute back pain has a favourable prognosis.4 The cornerstone of
acute back pain management focuses on empowering the patient
through education on the pathophysiology of the condition and
reassurance that it is mostly self-limiting. Patients should be
encouraged to remain as active as possible and engage in exer-
cise. Long-term participation in exercise formats that focus on
improving muscular quality and overall flexibility will reduce
both the frequency and the intensity of recurrent episodes.
Current evidence does not support the use of orthotics or
traction therapy. Massage and physiotherapy have a role in a
multidisciplinary approach, where psychological support can be
made available. Psychological support is vital if previous treat-
ment has been ineffective and there are significant psychological
barriers to recovery (yellow and blue flags); Figure 4.
Acupuncture, ultrasound and transcutaneous or percutaneous
electrical nerve stimulation have not been found to have any
benefit compared with placebo.
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Pharmacological approaches vary depending on whether
the focus is somatic or neuropathic. For musculoskeletal pain
and sciatica, appropriate and judicious use of non-steroidal
anti-inflammatory drugs (NSAIDs) is advised, using weak
opioids only if NSAIDs are contraindicated. Paracetamol
combined with weak opioids has a place but not as a sole
agent. A short course of benzodiazepines can be considered for
relief of localized muscular spasm in those who are at low risk
of dependency. There is no evidence to support atypical an-
algesics such as tricyclic antidepressants, gabapentinoids or
selective serotoninenoradrenaline reuptake inhibitors
(SNRIs).
With regards to managing the neuropathic element outside a
specialist pain service, tricyclic antidepressants or gabapenti-
noids should be first-line therapy. Short-term tramadol can also
be useful because of its dual effect of SNRI and m-receptor oc-
cupancy, but it is often poorly tolerated.
Non-surgical interventions such as spinal injections have no
place in acute back pain and can make the situation worse.
Lumbar medial branch blocks and subsequent radiofrequency
denervation have a place in chronic pain medicine when con-
servative management has not succeeded, and pain is rated at 5
or more on a numerical rating scale and is thought to be facetally
mediated.
Surgical advice currently veers away from disc replacement
and spinal fusion for back pain. Radicular pain can be managed
with decompressive approaches if conservative management has
not helped and there are appropriate radiological findings.
Cauda equina and its management
The cauda equina extends from the conus medullaris (usually
at L2) and consists of the second to fifth lumbar nerve pairs.
Cauda equina syndrome is a surgical emergency and occurs
when these nerves are suddenly and significantly compressed,
giving rise to sensory and motor issues. If it goes unrecognized
or untreated, severe neurological deficit may ensue. Despite
urgent management, some patients may never regain complete
neurological function. Of those who are unable to walk un-
aided on presentation, only half will go on to walk again.
However, the presentation is not always catastrophic, and
spotting the early signs and symptoms can be a diagnostic
challenge.
The most frequent cause is disc herniation. Rarer causes
include tumours, arteriovenous malformations, infection and
iatrogenic haematoma formation. The hallmarks are low
back pain, leg weakness, saddle anaesthesia and incontinence
(both urinary and faecal), sexual dysfunction can also be re-
ported. Urgent surgical decompression is the only available
treatment. A
KEY REFERENCES
1 Maniadakis N, Gray A. The economic burden of back pain in the
UK. Pain 2000; 84: 95e103.
2 Dunn KM, Jordan K, Croft PR. Characterising the course of low back
pain: a latent class analysis. Am J Epidemiol 2006; 163: 754e61.
3 Rea W, Kapur S, Mutagi H. Intervertebral disc as a source of pain.
Cont Educ Anaesth Crit Care Pain 2012; 12: 279e82.
5 Ó 2018 Published by Elsevier Ltd.
 MEDICINE AND OTHER SPECIALTIES

4 Pengel LH, Herbert RD, Maher CG, Refshauge KM. Acute low back National Institute for Health and Care Excellence. Low back pain and
pain: systematic review of its prognosis. Br Med J 2003; 327: 323. sciatica. 2016. NICE guideline no. NG59, www.nice.org.uk/
guidance/ng59.
FURTHER READING
Lavy C, James A, Wilson-McDonald J, Firbank J. Cauda equina syn-
drome. Br Med J 2009; 338: b936.

TEST YOURSELF
To test your knowledge based on the article you have just read, please complete the questions below. The answers can be found at the
end of the issue or online here.

Question 1 B. Weakness of plantar flexion of the foot and an absent knee

A 65-year-old woman presented with low back pain, cramping in reflex
the posterior aspect of both thighs and numbness radiating into C. Weakness of big toe extension and an absent ankle reflex
the feet on walking. It worsened with standing and walking, and D. Weakness of big toe extension and an absent patellar reflex
improved with sitting and bending forward. She had no bowel or E. Weakness of quadriceps extension and an absent patellar
bladder complaints. reflex
On clinical examination, there was full muscle strength, normal
sensation, normal reflexes and good peripheral pulses. A straight Question 3
leg raise test was negative. A 16-year-old girl presented with a 2-week history of low back
pain that worsened with activity and improved with rest. There
What is the most likely diagnosis? was no history of trauma. She had no systemic symptoms. She
A. Cauda equina syndrome was a gymnast.
B. Herniated disc On clinical examination, she was tender to palpation in the
C. Internal disc disruption lumbosacral region, with a restricted range of motion and tight
D. Spinal stenosis hamstrings. She had full strength and normal sensation
E. Vascular claudication throughout.

Question 2 Investigation
A 33-year-old man presented with a sudden onset of back and left  Oblique lumbar spine radiographs demonstrated a defect
leg pain after performing heavy squats at the gym. in the pars interarticularis

Investigation
 Following full neurological examination a MRI scan of the What is the best management option for this patient at this
spine was performed that confirmed a posterolateral left L5 time?
eS1 herniated disc A. Activity modification with therapeutic modalities
B. Computed tomography myelogram
What is a careful neurological examination likely to reveal? C. Selective nerve root injection
A. Weakness of plantar flexion of the foot and an absent ankle D. Surgical decompression
reflex E. Surgical decompression with spinal fusion

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