PAINE #PANCE Pearl – Musculoskeletal


What is a good mnemonic for the red flag history and/or symptoms of acute back pain?




The majority of the back pain you will see in clinical practice is non-emergent, but you need to be able to identify the cases that need emergent referral, consultation, or imaging.  Just remember TUNAFISH……


  1. Trauma
    1. Any trauma can cause fracture and cord compromise.  Back pain + trauma = imaging
  2. Unintentional weight loss
    1. Think vertebral metastasis of cancer
  3. Neurologic deficits
    1. Big ones are saddle anesthesia and bowel/bladder dysfunction.  Paresthesias, weakness, and numbness are concerning, but emergent.
  4. Age > 50
    1. New-onset back pain in patients > 50 years old can be cancer, infection, or AAA
  5. Fever
    1. Again…think osteomyelitis, spinal abscess, or cancer
  6. IVDU
    1. Hematogenous infectious seeding of the vertebral bodies or spinal abscess
  7. Steroid Use
    1. Chronic steroid use weakens bones and even low energy mechanisms or spontaneous fractures are possible
  8. History of cancer
    1. Metastases



  1. Della-Giustina D. Evaluation and treatment of acute back pain in the emergency department. Emergency medicine clinics of North America. 2015; 33(2):311-26. [pubmed]
  2. Borczuk P. An evidence-based approach to the evaluation and treatment of low back pain in the emergency department. Emergency medicine practice. 2013; 15(7):1-23; Quiz 23-4. [pubmed]
  3. FoamCast.  Episode 66 – Back pain and spinal epidural abscess.
  4. REBEL Review #56.  Red Flags of Back Pain.
  5. EM Cases.  Low Back Pain Emergencies.

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