Always consider potentially serious non-spinal causes of back or neck pain, including but not limited to ureteric colic, expanding abdominal aortic aneurysm, acute pancreatitis, aortic dissection and vertebral artery dissection.

A high index of suspicion and a low threshold for investigation should exist when considering spinal cord compression or cauda equina syndrome. The latter in particular is a clinical diagnosis. Emergency MRI imaging is needed and if delays are encountered, senior discussion should take place between the referring clinical specialty and Radiology immediately.

Always perform a perineal and perianal examination if you suspect spinal cord compression or cauda equina syndrome, for both clinical and medico-legal reasons. It is very useful and clinically prudent to document normal bladder motor function with a post-voiding bedside bladder scan.

In rectal examinations, references to ‘reduced’ anal tone are almost always extremely subjective and unhelpful; anal tone is better referred to as present or absent. It is also a very late sign of sacral nerve dysfunction. The absence of voluntary anal contraction is also unhelpful, as this occurs in many neurologically normal patients due to the unpleasant nature of the examination.

All patients requiring emergency MRI or CT scan may have a surgical diagnosis (e.g. cord compression, unstable spinal deformity) and should be kept nil by mouth pending their definitive imaging and discussion with a spinal surgeon. Keep the patient on bed rest; prescribe adequate analgesia; if there is significant sphincter involvement, particularly if in urinary retention, insert a bladder catheter.