Red Flags

Question 1

Fracture risk (8)

Answer 1

• Consider in acute presentations mainly
• Post trauma
• Sudden onset of pain
• Central deep pain
• Usually high severity
• Multidirectional provocation
• Osteoporosis / Osteoporotic risk
       o Female
          Age > 50 more so if > 70
       o Long term steroid use
       o Metabolic disease
       o Low BMI
       o Other non-traumatic fracture
• Acute spinal deformity (from physical)
• Bony tenderness (from physical)

Question 2

Infection risk (14)

Answer 2

• Recent significant open wound
• Post-surgery / invasive procedure
• Recent in-dwelling device (catheter)
• Recent infection (UTI etc)
• Immunosuppressed
• Cirrhosis
• HIV positive
• IV drug use
• Poor social environment
• Fevers
• Rigors
• Night sweats
• Unwell
• Hot locally

Question 3

Cancer risk (13)

Answer 3

• Insidious onset
• Constant unremitting pain
• Non-mechanical
• No relief with rest
• Unwell
• Associated systemic symptoms
• Unexplained weight loss
• Night pain
• Past history of cancer
• Family history of cancer
• Age > 50 years with first onset
• Cancer risk factors
• Worsening trajectory

Question 4

Neurological risk (17)

Answer 4

• Bilateral distribution
• Multiple spinal levels involved
• Severe weakness++ (even if single level)
• Progressive weakness++ (even if single level)
• Shingles (severe, non-mechanical pain, dermatomal rash)

CES
• Bladder dysfunction
• Bowel dysfunction
• Sexual dysfunction
• Saddle paraesthesia
• Saddle anaesthesia
• Low sacral distribution
     o (S2/S3 signs in physical)

Cord
• Sock/glove anaesthesia
• Sock/glove paraesthesia
• Unsteadiness 
• Clumsiness
• Falls and tripping
• Hyperreflexia

Question 5

Inflammatory risk (20)

Answer 5

• Persistent episodic pain
• Slow insidious onset
• Morning stiffness > ½ hour
• Morning worst time
• Wake second half of night
       o (Better when get up)
• Eased with activity
• Worse with rest
• NSAIDS help ++
• Multi joint involvement
• Hot/red/swollen peripheral joints
• Family history
• Eye redness
• Psoriasis
• Dry eyes/mouth
• Infection as a trigger
• Stomach problems related to joint pain
• Enthesopathies 
• Alternating SIJ pain
• Dactilitis 
• Significant loss of thoracic range

Question 6

Non Spinal Pathology - Abdominal aortic aneurysm (9)

Answer 6

o Acute presentations
o PVD/CAD
o Hypertensive
o Bruit 
o Over 60
o Smoker
o Pulsatile mass
o Abdominal pain
o Syncope