Red Flags

Question 1

What is a red flag?

Answer 1

Indicators of serious spinal pathology (e.g. maligancy, spinal infection, fracture, caudal equine)

Question 2

How to manage if a patient has one or more red flags?

Answer 2

One red flag = discuss with experienced practicioner

Cluster = further investigation required

Question 3

How many spinal red flags are there?

Answer 3

10

Question 4

What are the red flags (briefly)? (10)

Answer 4

• Age of onset
• Constant and progressive pain
• Violent Trauma
• PMH of cancer
• Unexplained weight loss
• Systemic Steroids
• IV drug use/HIV
• Structural deformities
• Night pain > day pain
• Sphincter Disturbance
• Wide spread neurological signs

Question 5

What is the red flag relating to age?

Answer 5

First episode under 20 or over 55

o Young people less prone to spinal pain
o Over 55 unusual because degenerative conditions come on slowly from middle age, and acute injuries without previous injury are unlikely in over 55s

Question 6

What is the red flag relating to pain type?

Answer 6

Constant progressive pain

o Indicates malignancy, discitis or other infectious pathology

Question 7

What is the red flag relating to mechanism of injury?

Answer 7

Violent trauma must be further investigated due to risk of fractures

Question 8

What is the red flag relating to PMH?

Answer 8

PMH of cancer - could indicate bony metastisis

Question 9

What is the red flag relating to unexplained weight loss?

Answer 9

Could indicate rheumatological disease or cancer

Question 10

What is the red flag relating to IV drug use/HIV?

Answer 10

Higher risk of infection (e.g. absesses or discitis)

Question 11

What is the red flag relating to Structural Deformities?

Answer 11

More treatable cause of pain:
o Excessive thoracic kyphosis
o Scoliosis
o Stepping in the lumbar spine - Indicates spondylolisthesis

Question 12

What is the red flag relating to diurnal pain pattern?

Answer 12

o If pain is worse at night than the day time

o If pain is worse lying down (not mechanical pain as better when offloaded)

Question 13

What is the red flag relating to sphincter disturbance?

Answer 13

If any new continence problems then could indicate cauda equina and should be looked into immediately

Question 14

What is the red flag relating to neurological signs?

Answer 14

If patient has widespread neurological signs and gait disturbance could indicate a CNS problem (e.g. MS)

Question 15

What is Cauda Equina Syndrome?

Answer 15

Compression of the cauda equina spinal nerve roots (due to tumor or spondylolythesis)

Question 16

Why is it essential to respond quickly to Cauda Equina Syndrome?

Answer 16

Possibility of nerve ischema and permemant damage - long term lower limb paralysis, sexual disfunction & permeant incontinence

Question 17

What are the signs of Cauda Equina Syndrome? (5)

Answer 17

o	Incontinence
o	Saddle anaesthesia
o	Sexual disturbance
o	Wide spread neurological signs
o	Gait disturbance