Mechanical spinal pain

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)
• Recent serious illness
• Recent significant infection
• Previous longstanding steroid use

Signs/Symptoms

• Saddle anaesthesia
• Reduced anal tone
• Urinary retention/incont
• Bowel incont
• Concordant erectile dysfunction
• Significant Hip or knee weakness
• Generalised neurological deficit
• Progressive spinal deformity
• Non-mechanical pain (worse at rest)
• Fevers/ rigours
• General malaise

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
• Cauda Equina syndrome features
• Hyper-reflexia
• Extensor plantars
• Clonus
• Altered hand function

Cauda Equina

• Bilateral radicular leg pain 
• Back pain
• Urinary retention/incont
• Perianal sensory loss
• Erectile dysfunction
• Reduced anal tone/Bowel incont

When to investigate red flags

• Urgent when red flags present
• Consider discussing with on-call reg.  
• To include:
  • Myeloma screen
  • ESR, CRP, FBC, U+E, Ca2+
  • Plain X-Ray particularly osteoporosis
  • Consider MRI – if there is an urgent need then contact the on call spinal reg who can authorise urgent imaging from primary care. Do not refer into ERS if there is an agreed need for urgent MRI imaging as this adds a delay