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Back pain (red flags)
From WikEM
Contents
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:
| 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
