Red flags in back pain

What are they?

Features, signs and symptoms in a patient with back pain which indicate serious spinal pathology

Features

  • Previous history malignancy (however long ago)
  • Age 16< or >50 with NEW onset pain
  • Weight loss (unexplained)
  • Previous longstanding steroid use
  • Recent serious illness
  • Recent significant infection

Signs

  • Saddle anaesthesia
  • Reduced anal tone
  • Hip or knee weakness
  • Generalised neurological deficit
  • Progressive spinal deformity
  • Urinary retention

Symptoms

  • Non-mechanical pain (worse at rest)
  • Thoracic pain
  • Fevers/ rigors
  • General malaise
  • Urinary retention

How to identify

  • High index of suspicion
  • Majority of information in history
  • Simple inspection of back with movement
  • Simple neurological examination
  • Heel/ toe walk, squat

Cord Compression

  • Back pain
  • Leg weakness
  • Limb numbness
  • Ataxia
  • Urinary retention (with overflow)
  • Hyper-reflexia
  • Extensor plantars
  • Clonus

Cauda Equina

  • Bilateral leg pain
  • Back pain
  • Urinary retention
  • Perianal sensory loss
  • Erectile dysfunction
  • Reduced anal tone

When to investigate red flags

  • Urgent when red flags present
  • To include:
    • Myeloma screen
    • ESR, CRP, FBC, U+E, Ca2+
    • Plain xray particularly osteoporosis / infection
    • Consider MRI