Back Pain Red Flags

Back pain is a common complaint with approximately 85% of the population experiencing back pain at some point in their lives. Across the world millions of people contact health practitioners everyday regarding back pain, more serious underlying pathologies are only found to be a cause in a low percentage of all cases. It is however, extremely important that any potential signs or symptoms of anything suspicious are recognised and thoroughly investigated.

What Does the Term Red Flag Mean?

back pain red flagsThe term red flag is a warning sign, it is used to describe certain factors or symptoms which may be indicative of a more serious underlying pathology such as cancer, infection immunosuppression, inflammation, Cauda Equina or spinal cord compression.

Back Pain Red Flags

One or more of the following symptoms accompanied by back pain are considered red flags and should be thoroughly investigated.

  • Systemic upset
    • night sweats, constant fever of 38C° or above
    • malaise
    • unexplained weight loss
  • Chronic or severe pain which prevents sleep
  • Swelling or any lumps on the back
  • History of cancer
  • Trauma
  • Abnormal gait
  • Immunosuppression, HIV
  • Drug abuse
  • Neurological symptoms – Cauda Equina/spinal cord compression

Cauda Equina

A medical emergency – Cauda Equina syndrome occurs when the nerves of the lower back exiting the spinal column (the Cauda Equina) all become compressed – if left untreated, it may have serious irreversible consequences such as paralysis.

Red Flags for Cauda Equina include:

  • Loss of bladder control
  • Loss of bowel control
  • Inability to pass urine
  • Numbness and loss of sensation around genitalia and arms
  • Sensory changes – perianal or saddle region with saddle anaesthesia or paraesthesia

Possible causes of Cauda Equina are:

  • Severe disc herniation
  • Spinal stenosis
  • Infection
  • Tumour

Spinal Cord Compression

Spinal cord compression is also a medical emergency and occurs when injuries and disorders put pressure on the spinal cord. It may be a result of:

  • Injury
  • Fractured vertebrae
  • Abnormal bone growth
  • Herniated disc
  • Tumour – typically cancer which has metastasised to the spine from another part of the body, or more rarely a tumour which has grown in the spine itself (this may or may not be cancerous)
  • An abscess

More Common Causes of Back Pain

There are numerous possible causes of back pain, including the following:

Cervical Region

  • Spondylosis – age related wear and tear processes
  • Fracture
  • Cervical radiculopathy
  • Cervical stenosis
  • Cervical myelopathy
  • Whiplash

Thoracic Back Pain

Less common than lumbar or cervical back pain, it is important to investigate the cause of thoracic back pain quickly to exclude any more serious underlying causes.

  • Fracture
  • Spondylosis – degeneration of the spinal structure
  • Kyphosis (Scheuremann’s disease – more common in younger patients)
  • Spinal arthritis

Lumbar Back Pain

  • Spondylosis – degenerative conditions – disc related problems are especially common due to the strain exerted on the lumbar discs
  • Sciatica – compression of the sciatic nerve is a common cause of lower back pain and referred pain and numbness to the buttocks and legs – Cauda Equina may result in compression of the Sciatic nerve
  • Fracture
  • Osteoporosis
  • Osteoarthritis
  • Scoliosis
  • Hyperlordosis

Red Flag Investigation

A detailed medical history and physical examination will be required to determine if there is evidence of neurological compromise, systemic disease further investigation may be required with appropriate testing such as MRI and blood tests. Any subsequent treatment will be determined by the diagnosis.

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