Low back pain is a common complaint in adults of all ages, and is being increasingly seen in children and adolescents. The lifetime occurrence of low back pain is around 59%.1 Mechanical low back pain is globally one of the most common presentations seen by the Emergency Physician.14 Most cases of low back pain treated in the

Emergency Department (ED) are not true emergencies, a notable exception being the Cauda Equina Syndrome (CES).

Owing to the low occurrence and low index of suspicion in the pediatric/adolescent age group, there may be a significant delay in diagnosis of Cauda Equina Syndrome. This is concerning, because delay in diagnosis and there by treatment, runs the risk of permanent neurological damage and disability. Unequivocally, the most common predictor of a favourable outcome in CES is early diagnosis.

We present the case of a 16-year-old male who presented to the ED on three separate occasions complaining of low back pain. The patient had red flag signs during the second visit; however, the relevant history and clinical findings were not elicited at the time. On the third ED visit, a clinical diagnosis of CES was made and urgent magnetic resonance imaging of the lumbo-sacral spine revealed a large right para-central herniation of the L4-L5 disc indenting the right L5 nerve root.

Our aim in highlighting this case is two fold:

1. To make the Emergency Physician aware of the rare diagnosis of CES in this uncommon

age group.

2. To stress the importance of early recognition of red flag signs in CES which will lead to an early diagnosis, and thereby a favourable outcome.