With saddle paresthesia, bowel incontinence and/or urinary retention, the immediate priority is to rule out Cauda Equina Syndrome. While Cauda Equina can occur in the presence of chronic back pain, it is the acute onset of the symptoms of saddle paresthesia, bowel incontinence and/or urinary retention that points to the diagnosis. 

Vertebral fractures may present with moderate to severe pain reproducible on exam usually with obvious trauma (or without in patients with osteoporosis or malignancies). B symptoms and a longer duration of pain may suggest malignancy. Muscle strain does not explain the neurological symptoms in this stem. Patients with infection present with new onset back pain, fever and often a history of IV drug use or recent infection.

Card: Low Back Pain A MC 001