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