"Red flag" symptoms & signs

Question 1

1. Back pain in the younger patient (<20 years)

Answer 1

significant back pain in childhood, adolescence or early adulthood is uncommon.

Younger children are more susceptible to infections (osteomyelitis, discitis) whilst adolescents are the peak age for spondylolisthesis as well as some benign (eg osteoid osteoma) and malignant (eg osteosarcoma) primary bone tumours.

Clinicians should have a low index of suspicion for referral or MRI.

Question 2

2. New back pain in the older patient (>60 years)

.

Answer 2

Back pain in the older patient may represent arthritic change or a crush fracture.

However patients in this age group are at higher risk of neoplasia, particularly metastatic disease and multiple myeloma.

Question 3

3. Nature of pain

Answer 3

constant, severe pain, worse at night

mechanical back pain is worse with activity and tends to be relieved by rest.

pain from tumour or infection tends to be constant, unremitting, severe and worse at night.

Question 4

4. Systemic upset

Answer 4

Fevers, night sweats, weight loss, fatigue and malaise may indicate the presence of underlying tumour or infection.

Any suspicion of underlying infection or tumour requires thorough history and examination with potential investigations including =

bloods (CRP, FBC, U&Es, bone biochemistry, plasma protein electrophoresis, PSA for males, blood culture if suspecting infection)

spine xray (may show vertebral collapse of loss of a pedicle on AP view)

chest xray

bone scan

MRI scan