Red flags

Back pain is common but we want to make sure that Derrick has not got any serious underlying pathology.

Red flag symptoms **

  • Cauda equina or cord compression

  • Trauma

  • History of cancer

  • Immunosuppression

  • Nocturnal pain

  • Systemic upset – unintentional weight loss, fevers, night sweats

  • Thoracic pain

  • Abnormal gait

  • History of steroid use

  • Age under 20 years or age over 55 years

  • History of osteoporosis

  • Associated lightheadedness

** NICE suggests that overall evidence for the use of red flags that may indicate serious spinal pathology in the primary care setting is not strongly established. The review suggests suspicion of spinal fracture or malignancy should not be made on the presence of a single red flag feature alone.

It is vital not to miss cauda equina syndrome, it is rare but can have devestating consequences. Spinal cord compression can have the same consequences if missed. It can present with bladder, bowel or sexual disturbances.

Other serious symptoms of back pain

  • Reduced sensation of the urinary system
  • Lack of desire to void or poor stream
  • New onset of faecal incontinence (caused by loss of sensation of a full rectum)
  • Sensory changes in the perianal or saddle region with saddle anaesthesia or paraesthesia
  • Sensory changes and weakness in the lower limbs
  • Malignant spread (lung, prostate, breast, thyroid or kidney), or myeloma

The pain may remain on lying down, aching night time pain which disturbs sleep and thoracic pain (which can also be a sign of other causes like aortic aneurysm).