What Raises Concern With Back Pain
Ask an Expert. Emergency physician Dr. Tiffany Sanders Alima explains how back pain is evaluated in the ER and the warning signs that raise concern.
What is your first thought when a patient comes in with back pain?
My first thought is that the pain is likely musculoskeletal, meaning it is coming from the muscles, joints, ligaments, discs, or other structures in the back rather than something more dangerous underneath.
But in emergency medicine, one of the easiest mistakes is anchoring too quickly, meaning settling on the most obvious explanation before fully considering the more serious causes of back pain. Most of the time, the pain is not coming from something dangerous but that cannot just be assumed at the door.
The goal is not only to recognize the common explanation. It is also to make sure the emergent causes are not being missed.
What do patients often misunderstand about back pain?
Two things come up all the time.
First, it is actually okay to try over-the-counter medications and supportive care before coming to the ER if there are no alarming associated symptoms. Second, not all back pain requires an MRI, which is a detailed imaging scan used to look closely at the spine, nerves, discs, and surrounding tissues. In fact, most does not.
A lot of back pain can be evaluated based on the history, physical exam, and overall clinical picture, meaning the full pattern of symptoms, exam findings, and context, without advanced imaging right away.
What red flags make you worry?
The biggest red flags are saddle anesthesia, which means numbness in the groin, buttocks, or inner thighs, fever with back pain in someone with IV drug use, meaning injection drug use, and back pain with no distal pulses, meaning weak or absent pulses in the feet or lower legs.
Those findings immediately raise concern for something more serious than routine musculoskeletal pain.
They are the kinds of clues that shift the evaluation away from “this is probably a strain” and toward conditions that need a much closer look.
THE BOTTOM LINE
Most back pain is likely musculoskeletal. What matters most is not just the pain itself but whether it comes with features that suggest something more serious underneath.
That is where the red flags matter.
About the Expert
Tiffany Sanders Alima, DO is a Board-Certified Emergency Physician.
This article is for educational purposes only and is not a substitute for medical advice from your own healthcare provider.