GP assessment for Acute Low Back Pain with radicular symptoms
(please use in conjunction with MSK referral if patient needs referring to MSK)
Patient Name:
DOB:
NHS Number:
History of Present Condition (Including timeframes, nature of pain and onset):
Relevant Past Medical History (e.g. previous cancer or serious illness/infection):
Key Questions (essential to ask):
Symptoms indicative of Cauda Equina Syndrome:
Urinary incontinence/retention present on day of assessment
Timescale:
Yes
No
Faecal incontinence present on day of assessment
Timescale:
Yes
No
Altered sensation in saddle area present on day of assessment
Timescale:
Yes
No
Patients who report any of the above which are present on the day of attendance and are less
than 3 months in duration should be immediately referred to the Emergency Department.
Isolated constipation would not be an indication for an emergency MRI since this is a
common symptom with back pain and is often related to codeine related products.
Symptoms indicative of a potential Cauda Equina Syndrome/more serious
neurological cause - Requiring urgent medical screening assessments +/- MRI
before considering referral to MSK
Patients who present with:







Significant motor weakness e.g. Isolated foot drop
Progressive neurological deficit in lower extremities
Bilateral true sciatica
Spinal pain/Sciatica with urological symptoms, e.g. stress incontinence, bladder
frequency, urgency.
A report of any of the following but not present on the day of attendance or are
greater than 3 months in duration.
o Saddle area numbness,
o Urinary incontinence/retention
o Faecal incontinence
Sexual dysfunction
Paresis (gait disturbance)
(Adapted from the Cauda Equina pathway developed by the MSK service)
1
Neurological assessment, see videofor guidance. Ensure sufficient analgesia for
accurate assessment, severe pain may need strong analgesia for rapid relief to enable
assessment. Please see Analgesia Ladder in the ‘Pathway for patients presenting with new
on-set motor loss in the presence of acute low back and radicular pain’ in RSS.
Assessment
Right Lower Limb
Left Lower Limb
guidance
Ankle Plantar
Patient asked to
Achieved
Achieved
Flexion
stand on one leg
Not achieved
Not achieved
(L5/S1)
and heel raise
(with support)
Ankle
Patient lying on
Normal
Normal
Dorsiflexion
back or sitting on
Reduced
Reduced
(L4/L5)
edge of plinth
Absent
Absent
Hallux
Patient lying on
Normal
Normal
Dorsiflexion
back or sitting on
Reduced
Reduced
(L5)
plinth
Absent
Absent
Knee
Patient sitting on
Normal
Normal
extension
edge of plinth
Reduced
Reduced
(L2-L4)
Absent
Absent
Knee Flexion
Patient sitting on
Normal
Normal
(L5-S2)
edge of plinth
Reduced
Reduced
Absent
Absent
Hip Flexion
Patient sitting on
Normal
Normal
(L2)
edge of plinth
Reduced
Reduced
Absent
Absent
Sensation
Pin prick test
Normal
Normal
across lower leg
Reduced
Reduced
dermatomes (see If reduced state
If reduced state which
figure below)
which
dermatome(s)3:
dermatome(s)3:
Ankle Reflex
(S1)
Babinski
Response1
Knee Reflex
(L3/L4)
Patient in lying or
sitting
Consider
Jendrassik
Manoeuvre1 to aid
assessment
Patient in lying or
sitting
Present
Reduced
Absent
Brisk
Present
Reduced
Absent
Brisk
Present
Absent
Present
Absent
Patient in lying or
sitting
Consider
Jendrassik
Manoeuvre2 to
validate findings
Present
Reduced
Absent
Brisk
Present
Reduced
Absent
Brisk
1When
the Babinski response is present in an adult, it is often a sign of a brain or nervous system
disorder.
2Jendrassik
Manoeuvre is a distraction technique used to overcome the voluntary suppression of
reflexes. The patient hooks the flexed fingers of the two hands together and forcibly tries to pull them
apart; while this tension is being exerted the lower extremity reflexes are tested.
2
3The
‘evidence based’ dermatome map representing the most consistent tactile dermatomal areas
for each spinal dorsal nerve root found in most individuals, based on the best available evidence.
The dermatomal areas shown are not autonomous zones of cutaneous sensory innervation,
except across the midline where overlap is minimal, adjacent dermatomes overlap to a large and
variable extent. Blank regions indicate areas of major variability and overlap. S3, S4 and S5
supply the perineum but are not shown separately (Keegan and Garrett, 1948). Note consecutive
dermatomes shown in buff or blue for clarity. From Apok, Gurusinghe, Mitchell and Elmsley
(2011). Neurological Sign. Dermatomes and Dogma. Practical Neurology. 11:100-105.
3