Red flag symptoms and signs of back pain

Question 1

List the red flags for back pain

Answer 1

Aged <20 or >55
Acute onset in elderly
Constant or progressive pain
Nocturnal pain
Worse pain on being supine
Fever, night sweats, weight loss
History of malignancy
Abdominal mass
Thoracic back pain
Morning stiffness
Bilateral or alternating leg pain
Neurological disturbance (inc. sciatica)
Sphincter disturbance
Current or recurrent infection
Immunosuppression
Leg claudication or exercise-related leg weakness/numbness (spinal stenosis)

Question 2

Name 5 serious causes of low back pain

Answer 2

Cauda equina syndrome
Spinal fracture
Cancer
Infection e.g. discitis, vertebral osteomyelitis, spinal epidural abscess

Question 3

What red flags are suggestive of Cauda equina syndrome?

Answer 3

Severe or progressive bilateral neurological deficits in legs
Recent-onset urinary retention and/or urinary incontinence, or sexual problems
Recent-onset faecal incontinence
Saddle anaesthesia
Unexpected laxity of anal sphincter (on DRE)

Question 4

Define Cauda equina syndrome

Answer 4

Symptoms due to compression of spinal nerve roots (cauda equina): Bilateral leg weakness, abnormal gait, saddle anaesthesia, urinary and faecal incontinence, sexual problems.

Question 5

What red flags are suggestive of spinal fracture?

Answer 5

Sudden onset of severe central spinal pain, relieved by lying down
History of major trauma, minor trauma, or lifting in those on corticosteroids or with osteoporosis
Structural deformity of the spine (step appearance on spinal XR)
May be point tenderness over vertebral body

Question 6

What red flags are suggestive of spinal cancer?

Answer 6

> 50yrs
Gradual onset of symptoms
Severe unremitting pain, remains when supine, aching night pain, pain aggravated by straining, thoracic pain
Localised spinal tenderness
No symptomatic improvement after 4-6wk of conservative back pain therapy
Unexplained weight loss
PHx of cancer - esp. breast, lung, GI, prostate, renal, thyroid

Question 7

Which primary cancers are more likely to metastasise to the spine?

Answer 7

Breast
Lung
GI
Prostate
Renal
Thyroid

Question 8

What red flags are suggestive of spinal infection?

Answer 8

Fever
TB or recent UTI
Diabetes
Hx of IVDU
HIV, corticosteroids, or immunocomprimised