TABLE 3

Red Flags for Acute Low Back Pain

History Bladder or bowel incontinence

Cancer Urinary retention (with overflow incontinence)

Unexplained weight loss Physical examination

Immunosuppression Saddle anesthesia

Prolonged use of steroids Loss of anal sphincter tone

Intravenous drug use Major motor weakness in lower extremities

Urinary tract infection Fever

Pain that is increased or unrelieved by rest Vertebral tenderness

Fever Limited spinal range of motion

Significant trauma related to age (e.g., fall from a height or motor

Neurologic
vehicle findings persisting beyond one month
accident in a young patient, minor fall or heavy lifting in a potentially
osteoporotic or older patient or a person with possible osteoporosis)

TABLE 1
Causes of Low Back Pain
CONDITION CLINICAL CLUES

Nonspecific back pain (mechanical back pain, No nerve root compromise, localized pain over
facet joint pain, osteoarthritis, muscle sprains, lumbosacral area
spasms)

Sciatica (herniated disc) Back-related lower extremity symptoms and spasm in

radicular pattern, positive straight leg raising test

Spine fracture (compression fracture) History of trauma, osteoporosis, localized pain over spine

Spondylolysis Affects young athletes (gymnastics, football, weight

lifting); pain with spine extension; oblique radiographs
show defect of pars interarticularis

Malignant disease (multiple myeloma), Unexplained weight loss, fever, abnormal serum protein
metastatic disease electrophoresis pattern, history of malignant disease

Connective tissue disease (systemic lupus Fever, increased erythrocyte sedimentation rate, positive
erythematosus) for antinuclear antibodies, scleroderma, rheumatoid
arthritis

Infection (disc space, spinal tuberculosis) Fever, parenteral drug abuse, history of tuberculosis or
positive tuberculin test
 CONDITION CLINICAL CLUES

Abdominal aortic aneurysm Inability to find position of comfort, back pain not relieved
by rest, pulsatile mass in abdomen

Cauda equina syndrome (spinal stenosis) Urinary retention, bladder or bowel incontinence, saddle
anesthesia, severe and progressive weakness of lower
extremities

Hyperparathyroidism Insidious, associated with hypercalcemia, renal stones,

constipation

Ankylosing spondylitis (morning stiffness) Mostly men in their early 20s, positive for HLA-B27
antigen, positive family history, increased erythrocyte
sedimentation rate

Nephrolithiasis Colicky flank pain radiating to groin, hematuria, inability

to find position of comfort

Cord Compression
Red flags in back pain  Back pain
What are they?  Leg weakness
Features, signs and symptoms in a patient with back  Limb numbness
pain which indicate serious spinal pathology  Ataxia
 Urinary retention (with overflow)
Features  Hyper-reflexia
 Previous history malignancy (however long  Extensor plantars
ago)  Clonus
 Age 16< or >50 with NEW onset pain Cauda Equina
 Weight loss (unexplained)  Bilateral leg pain
 Previous longstanding steroid use  Back pain
 Recent serious illness  Urinary retention
 Recent significant infection  Perianal sensory loss
Signs  Erectile dysfunction
 Saddle anaesthesia  Reduced anal tone
 Reduced anal tone When to investigate red flags
 Hip or knee weakness  Urgent when red flags present
 Generalised neurological deficit  To include:
 Progressive spinal deformity  Myeloma screen
 Urinary retention  ESR, CRP, FBC, U+E, Ca2+
Symptoms  Plain xray particularly
 Non-mechanical pain (worse at rest) osteoporosis / infection
 Thoracic pain  Consider MRI
 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
Yellow Flags in Back Pain
 Inappropriate attitudes and beliefs about back
pain
 Inappropriate pain behaviour
 Work related problems or compensation issues
 Emotional problems
“Risk Factors for Chronicity”
Early management of these factors may have a
significant impact on prognosis
They include the following;
 Previous history of Low Back Pain (LBP)
 Total work loss (due to LBP) in the last 12 months
 Radiating leg pain
 Reduced Straight Leg Raising
 Signs of nerve root involvement
 Reduced trunk muscle strength
help and self management they will return
to normal activities?
 Beliefs - The most common misguided
belief is that the patient feels they have
something serious causing their problem-
usually cancer. 'Faulty' beliefs can lead
to catastrophisation.
 Compensation - Is the patient awaiting
payment for an accident/ injury at work/
RTA?
 Diagnosis - or more
importantly Iatrogenesis. Inappropriate
communication can lead to patients
misunderstanding what is meant, the most
common examples being 'your disc has
popped out' or 'your spine is crumbling'.
 Emotions - Patients with other emotional
difficulties such as ongoing depression
and/or anxietous states are at a high risk of
developing chronic pain.
 Family - There tends to be two problems
with families, either over bearing or under
supportive.
 Work - The worse the relationship, the
more likely they are to develop chronic
LBP.

 Poor physical fitness

 Heavy smoking

 Self-rated poor health

 Psychological distress

 Depressive symptoms

 Disproportionate illness behaviour

 Low job satisfaction

 Personal Problems

 Medico-legal proceedings
Yellow flags in back pain
The most important and widely used model for the
examination of the spine is the Bio-Psycho-Social
model. This aims to encompass all elements of a
patient's problem. The aim of the psychosocial
assessment is to find those patients who are likely to
develop chronicity. The factors which highlight the
patient's risk of chronicity can be identified using the
'yellow flags' system:
 Attitudes - towards the current problem.
Does the patient feel that with appropriate
 Red flags for neck pain
A serious underlying cause is more likely in people
presenting with:
 New symptoms before the age of 20 years or after
the age of 55 years
 Weakness involving more than one myotome or
loss of sensation involving more than one
dermatome
 Intractable or increasing pain
Red flags suggesting possible malignancy, infection
or inflammation:
 Fever
 Unexplained loss of weight
 History of inflammatory arthritis
 History of malignancy, drug abuse, tuberculosis,
AIDS, or other infection
 Immunosuppression
 Pain that is increasing, unremitting and/or disturbs
sleep
 Lymphadenopathy
 Exquisite localised tenderness over a vertebral
body
Red flags suggesting myelopathy (compression of the
spinal cord):
 Insidious progression
 Gait disturbance; clumsy or weak hands; loss of
sexual/bladder/bowel function
 Lhermitte's sign (flexing the neck causes electric
shock-like sensations that extend down the spine
and shoot into the limbs)
 Upper motor neurone signs in the lower limbs
(Babinski's sign - up-going plantar reflex,
hyperreflexia, clonus, spasticity)
 Lower motor neurone signs in the upper limbs
(atrophy, hyporeflexia)
 Variable sensory changes (loss of vibration and
joint position sense more evident in the hands
than in the feet)
Red flags suggesting severe trauma/skeletal injury:
 History of trauma
 Previous neck surgery
 Osteoporosis or risk factors for osteoporosis
 Increasing and/or unremitting pain
Red flags suggesting vascular insufficiency:
 Dizziness and blackouts (restriction of vertebral
artery) on movement, especially on extension of
the neck with upward gaze
 Dizziness, drop attacks
Red flags for back pain
 Red flags that suggest cauda equina syndrome
include:
 Severe or progressive bilateral neurological
deficit of the legs, such as major motor
weakness with knee extension, ankle
eversion, or foot dorsiflexion.
 Recent-onset urinary retention (caused by
bladder distension because the sensation of
fullness is lost) and/or urinary incontinence
(caused by loss of sensation when passing
urine).
 Recent-onset faecal incontinence (due to loss
of sensation of rectal fullness).
 Perianal or perineal sensory loss (saddle
anaesthesia or paraesthesia).
 Unexpected laxity of the anal sphincter.
 Red flags that suggest spinal fracture include:
 Sudden onset of severe central spinal pain
which is relieved by lying down.
 History of major or minor trauma, or even
just strenuous lifting in people with
osteoporosis.
 Structural deformity of the spine (eg, a step
from one vertebra to an adjacent vertebra).
 Point tenderness over the vertebral body, or
pathological fracture.
 Red flags that suggest cancer or infection (such as
discitis, vertebral osteomyelitis, or spinal epidural
abscess) include:
 Onset in people older than 50 years, or
younger than 20 years of age.
 Pain that remains when supine, aching night
pain that disturbs sleep, and thoracic pain.
 Past history of cancer (breast, lung,
gastrointestinal, prostate, renal, and thyroid
cancers are more likely to metastasise to the
spine).
 Fever, chills or unexplained weight loss.
 Recent infection (eg, urinary tract infection).
 Intravenous drug misuse.
 Immunocompromise such as HIV infection.
 Red flags that suggest spondyloarthropathy
include:
 Early morning stiffness lasting >45 minutes.
 Night pain.
 'Gelling'.
 Easier with movement/worse after rest.
 Red flags that suggest a high risk of permanent
damage to the compressed nerve include:
 Significant muscle weakness or wasting.
 Loss of tendon reflexes.
 Presence of a positive Babinski reflex (toes
extend and fan outwards when the lateral
part of the sole of the foot is stimulated).
 Presentation  Cord compression in the thoracic spine can
produce paraplegia.
Lumbosacral disc herniation  There may be clonus or a positive Babinski
reflex.
 If there is nerve entrapment in the lumbosacral  There may be bladder/bowel dysfunction.
spine, this leads to symptoms of sciatica which  Herniation of T2-T5 can mimic cervical disc
include:[1]
disease.
 Unilateral leg pain which radiates below
the knee to the foot/toes.
 The leg pain being more severe than the
back pain.
 Numbness, paraesthesia, weakness and/or
loss of tendon reflexes, which may be
present and are found in the same
distribution and only in one nerve root
distribution.
 A positive straight leg raising test (there is
greater leg pain and/or more nerve
compression symptoms on raising the leg).
 Pain which is usually relieved by lying down
and exacerbated by long walks and
prolonged sitting.
 The functional distribution of the lumbar nerve
roots and the sciatic nerve are detailed in the
separate Low Back Pain and Sciatica article.
 Large herniations can compress the cauda
equina, leading to symptoms/signs of saddle
anaesthesia, urinary retention and incontinence
as described above.
 Symptoms tend at least to resolve partially in
66% of people with a disc herniation, after six
months. This is because the herniated portion
tends to regress over time.[2]
 However, nerve root compression can lead to
permanent nerve damage with sensory and
motor deficit.[1]

Thoracic disc herniation

 Disc lesions in the thoracic spine can lead either

to nerve root irritation or to cord compression.
 Thoracic spine lesions can present with
symptoms similar to lumbar disc lesions.
 In nerve root irritation, there may be shooting
pain down the legs.
 There may be pain, paraesthesia or dysaesthesia
in a dermatomal distribution.
 A thoraco-abdominal sensory examination can
help to determine the level of the lesion: the
nipple is innervated by T4; the xiphoid by T7; the
umbilicus by T10; the inguinal region by T12.
 Testing of the abdominal and cremasteric
reflexes can help to identify myelopathy and
cord compression.
 Cord compression:
 This is a neurosurgical emergency.