Back pain (red flags)

General

Although there are many red flags of back pain on history and physical, meta-analysis has show the following to be predictive of fracture or malignancy:

Back Pain Risk factors and probability of Fracture or Malignancy

Factor	Post Test Probability
Older Age (>65yo)	9% (95% CI 3% to 25%)
Prolonged corticosteroid	33% (95% CI 10% to 67%)
Severe trauma	11% (95% CI 8% to 16%)
Presence of contusion or abrasion	62% (95% CI 49% to 74%)
Multiple red flags	90% (95% CI 34% to 99%)
Hx of malignancy	33% (95% CI 22% to 46%)

History

• Pain >6wk (tumor, infection)
• Age >50 or <18 (tumor, congenital anomaly)
• History of trauma
• History of IVDU
• History of cancer
• History of sciatica
• Neurological complaints (paresthesias, anesthesia, weakness)
• Urinary retention
• Incontinence of bowel/bladder
• Night pain
• Unremitting pain, even when supine
• Fever, chills, night sweats
• Anticoagulants/coagulopathy

Physical Exam

• Fever
• Patient writhing in pain
• Anal sphincter laxity
• Perianal/perineal sensory loss (Saddle Anesthesia)
• Palpable bladder post voiding or abnormal post void residual
• Point vertebral tenderness
• Neurological deficits
• Positive straight leg raise

Specific Condition Red Flags

Cancer Related

• History of back pain
• Weight loss >10kg in 6mo
• Age >50 or <18
• No improvement despite therapy
• Pain for >4-6wks
• Night pain
• Pain worse at rest
• Vertebral tenderness
• Multiple nerve roots affected

Infection Related

• Persistent fever
• History of IVDA
• Recent infection
• Immunocompromised state
  • HIV
  • Systemic corticosteroids
  • Transplant
  • DM

Cauda Equina

• Incontinence or retention
• Saddle anesthesia
• Decreased anal sphincter tone
• Bilateral lower extremity weakness or numbness
• Neurologic deficit

Herniated Disc

• Muscle Weakness
• Radiation of pain
• Footdrop

Vertebral Fracture

• Prolonged use of corticosteroids
• History of osteoporosis
• Age>70
• Mild trauma in age >50yr
• Significant trauma in any age
• Bony tenderness

AAA

• Risk factors for PVD
• Pulsating mass
• Pain at rest or at night
• Age >60yrs

See Also

• Lower back pain

References

Authors

Neil Young