II. Precautions

  1. Low back red flag check lists have poor Test Specificity
    1. Many patients with Low Back Pain have at least one red flag (>80%)
  2. Evaluate red flags in the context of the clinical presentation as a whole
    1. Keep a high index of suspicion in high risk patients or where more than one red flag is present
    2. Positive red flags are typically indications for imaging

III. Red Flags: Summary (Mnemonic: TUNA FISH, as an aid to documentation)

  1. T - Trauma
  2. U - Unexplained Weight Loss
  3. N - Neurologic findings (includes bowel or bladder Incontinence and other Cauda Equina Syndrome symptoms)
  4. A - Age >55 years (or age >65 years)
  5. F - Fever
  6. I - Immunocompromised
  7. S - Steroids
  8. H - History of HIV, Tuberculosis, Cancer
  9. References
    1. Mallon (2019) CCME EM Board Review, Las Vegas, accessed 8/1/2019

IV. Red Flags: Cancer Related Red Flags with Low Back Pain

  1. See Spinal Neoplasm
  2. History of cancer (esp. recent)
    1. Breast Cancer
    2. Lung Cancer
    3. Prostate Cancer
    4. Renal Cancer
    5. Gastrointestinal Cancer
    6. Thyroid Cancer
    7. Multiple Myeloma
    8. Non-Hodgkin's Lymphoma
  3. Unexplained Weight Loss >10 kg within 6 months
  4. Age over 50 years or under 18 years old
  5. Failure to improve with therapy
  6. Pain persists for more than 4 to 6 weeks
  7. Night pain or pain at rest

V. Red Flags: Infection Related Red Flags with Low Back Pain

VI. Red Flags: Cauda Equina Syndrome Related Red Flags with Back Pain

  1. See Cauda Equina Syndrome
  2. Urinary Incontinence or retention
  3. Saddle Anesthesia
  4. Anal sphincter tone decreased or Fecal Incontinence
  5. Bilateral lower extremity weakness or numbness
  6. Progressive neurologic deficit
    1. Major motor weakness
    2. Major sensory deficit

VII. Red Flags: Significant Herniated nucleus pulposus

  1. Major Muscle Weakness (strength 3 of 5 or less)
  2. Foot Drop

VIII. Red Flags: Vertebral Fracture related red flags with Low Back Pain

  1. See Thoracolumbar Trauma
  2. See Vertebral Compression Fracture
  3. Prolonged use of Corticosteroids
  4. Age greater than 70 years
  5. History of Osteoporosis
  6. Mild Trauma over age 50 years (or with Osteoporosis)
  7. Recent significant Trauma at any age
    1. Ejection from motor vehicle
    2. Fall from substantial height

IX. Red Flags: Abdominal Aortic Aneurysm red flags with Low Back Pain

  1. Risk Factors (males over age 65 years with a history of Tobacco Abuse)
  2. Abdominal pulsating mass
  3. Atherosclerotic vascular disease
  4. Pain at rest or nocturnal pain
  5. Renal Colic presentation without a history of known aneurysm

X. Red Flags: General (weak Test Specificity)

  1. Vertebral tenderness
  2. Limited spine range of motion

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Low Back Pain (C0024031)

Definition (MSH) Acute or chronic pain in the lumbar or sacral regions, which may be associated with musculo-ligamentous SPRAINS AND STRAINS; INTERVERTEBRAL DISK DISPLACEMENT; and other conditions.
Definition (AOT) see:http://www.nlm.nih.gov/mesh/MBrowser.html
Concepts Sign or Symptom (T184)
MSH D017116
ICD9 724.2
ICD10 M54.5
SnomedCT 156651006, 268083007, 202793005, 156648004, 40709005, 139421003, 267169009, 279039007
English Back Pain, Low, Back Pains, Low, Low Back Pains, Lumbago, Low Back Ache, Low Backache, Lower Back Pain, Ache, Low Back, Aches, Low Back, Back Ache, Low, Back Aches, Low, Back Pain, Lower, Back Pains, Lower, Backache, Low, Backaches, Low, Low Back Aches, Low Backaches, Lower Back Pains, Pain, Lower Back, Pains, Lower Back, LUMBAR PAIN, Pain, Low Back, Pains, Low Back, Nonspecific pain lumbar region, low back pain (symptom), lower back pain, lumbago (diagnosis), lumbar back pain, lumbar pain, lumbago, low back pain, Low back ache, Lumbago NOS, Low Back Pain [Disease/Finding], lumbalgia, Pain;back low, Pain;back;lumbar, low backache, low back pains, lower back pains, lumbar pains, Lower back pain, LBP - low back pain, Low back pain (disorder), Lumbago (disorder), backache lower, lower backache (diagnosis), lower backache, Low back pain, Low back syndrome, Lumbalgia, LBP - Low back pain, Nonspecific pain in the lumbar region, Lumbar pain, back; pain, low, backache; low, low back; pain, low; backache, pain; back, low, pain; low back, syndrome; low back, Lumbago (disorder) [Ambiguous], Low back pain (finding), Low Back Pain
Portuguese DOR LOMBAR, Moinha lombar, Dor lombar, Lombalgia, Dor Lombar, Lumbago
Dutch lumbago, pijn in de onderrug, lage rugpijn, lumbaalpijn, laag; rugpijn, lage rug; pijn, pijn; lage rug, pijn; onderste deel van rug, pijn; rug, laag, rug; pijn, laag, rugpijn; laag, syndroom; lage rug, Lage rugpijn, Lagerugpijn, Lumbago, Pijn, lagerug-
French Endolorissement de la région lombaire, Douleur dans la partie inférieure du dos, Douleur lombosacrale, DOULEUR LOMBAIRE, Douleur dorsale basse, Douleur lombaire basse, Douleur du bas du dos, Rachialgie lombo-sacrale, Rachialgie lombo-sacrée, Rachialgie lombosacrale, Rachialgie lombosacrée, Rachialgie lombaire, Lombalgie, Lumbago, Douleur lombaire, Douleur lombosacrée
German unterer Rueckenschmerz, unterer Rueckenschmerzen, lumbaler Schmerz, Kreuzschmerz, SCHMERZ LENDENGEGEND, Kreuzschmerzen, Lumbago, Lumbalsyndrom, Hexenschuß
Italian Dolore dorso-lombare, Lombalgia, Lombaggine, Dolore lombare
Spanish Dolor de la parte baja de la espalda, Dolor lumbar, dolor de espalda, LUMBAR, DOLOR, lumbalgia (trastorno), síndrome de dolor en la región inferior de la espalda, Lumbalgia, dolor inespecífico en la región lumbar, dolor lumbar, lumbago, lumbalgia (concepto no activo), lumbalgia (hallazgo), lumbalgia, Lumbago, Dolor de la Región Lumbar
Swedish Ländryggssmärta
Japanese ヨウツウショウ, ヨウツウ, 腰痛, 腰痛症
Czech lumbalgie, bolest v kříži, lumbago, Bolest dolní poloviny zad, Bederní bolest, Lumbago, ústřel, bolest bederní páteře, bolesti bederní páteře, bederní bolest
Finnish Alaselkäkipu
Korean 아래허리통증
Polish Ból krzyża, Ból dolnego odcinka kręgosłupa, Lumbago, Ból okolicy lędźwiowo-krzyżowej
Hungarian Lumbago, Alsó háti fájdalom, derékfájás, Derékfájdalom, Lumbalis fájdalom
Norwegian Lumbago, Hekseskudd, Korsryggssmerter

Ontology: Aortic Aneurysm, Abdominal (C0162871)

Definition (NCI) Enlargement and ballooning of the vessel that supplies arterial blood to the abdomen, pelvis and legs.
Definition (MSH) An abnormal balloon- or sac-like dilatation in the wall of the ABDOMINAL AORTA which gives rise to the visceral, the parietal, and the terminal (iliac) branches below the aortic hiatus at the diaphragm.
Concepts Disease or Syndrome (T047)
MSH D017544
SnomedCT 155422008, 233985008
English Aortic Aneurysm, Abdominal, Abdominal Aortic Aneurysms, Aneurysms, Abdominal Aortic, Aortic Aneurysms, Abdominal, AAA-Abdominal aortic aneurysm, ABDOMINAL AORTIC ANEURYSM, ANEURYSM, ABDOMINAL AORTIC, Abdominal Aortic Aneurysm, AAA (abdominal aorta aneurysm), aneurysm of abdominal aorta, aneurysm of abdominal aorta (diagnosis), Abdominal aneurysm, Aneurysm of abdominal aorta, abdominal aorta aneurysm, abdominal aortic aneurysm, AAA (abdominal aortic aneurysm), AAA, Aortic Aneurysm, Abdominal [Disease/Finding], Aneurysm;abdominal aortic, abdominal aneurysm, abdominal aortic aneurysms, abdominal aneurysms, aneurysm abdominal, abdominal aortic aneurysm (AAA), Aneurysm, Abdominal Aortic, AAA - Abdominal aortic aneurysm, Abdominal aortic aneurysm, Abdominal aortic aneurysm (disorder), abdominal; aneurysm, aneurysm; abdominal aorta, aneurysm; abdominal, aorta abdominalis; aneurysm
Dutch abdominaal aneurysma, aneurysma van aorta abdominalis, aneurysma aorta abdominalis, abdominaal; aneurysma, aneurysma; abdominaal, aneurysma; aorta abdominalis, aorta abdominalis; aneurysma, Aneurysma aortae abdominalis
French Anévrysme abdominal, AAA (Anévrisme de l'Aorte Abdominale), Anévrisme aortique abdominal, Anévrysme aortique abdominal, Anévrisme de l'aorte abdominale, Anévrysme de l'aorte abdominale, Anévrisme abdominal aortique, Anévrismes abdominaux aortiques, Anévrysme abdominal aortique, Anévrysmes abdominaux aortiques
German Aneurysma der Bauchaorta, Aneurysma, Aorta, abdominales, Aortenaneurysma, abdominales, Aneurysma, Bauchaorten-, Bauchaortenaneurysma
Italian Aneurisma dell'aorta addominale, Aneurisma addominale, Aneurisma aortico addominale
Portuguese Aneurisma abdominal, Aneurisma da aorta abdominal, Aneurisma da Aorta Abdominal
Spanish Aneurisma de la aorta abdominal, Aneurisma aórtico abdominal, Aneurisma abdominal, Aneurisma de la Aorta Abdominal, Aneurisma de Aorta Abdominal, Aneurisma Aórtico Abdominal, aneurisma de aorta abdominal (trastorno), aneurisma de aorta abdominal
Swedish Aortabråck, buk
Japanese フクブダイドウミャクリュウ, 大動脈瘤-腹部, 腹大動脈瘤, 腹部大動脈瘤
Finnish Vatsa-aortan aneurysma
Czech Aneurysma břišní aorty, Břišní aneurysma, aorta abdominalis - aneurysma, aneurysma abdominalní aorty
Polish Tętniak aorty brzusznej
Hungarian Hasi aorta aneurysma, Aorta abdominalis aneurysmája, Abdominalis aneurysma
Norwegian Bukaortaaneurisme, Abdominalt aortaaneurisme

Ontology: Fracture of lumbar spine (C0262544)

Definition (NCI) A fracture of one of the lumbar vertebra.
Concepts Injury or Poisoning (T037)
ICD10 S32.0
SnomedCT 207987002, 125608002
Italian Frattura di vertebra lombare
Japanese 腰椎骨折, ヨウツイコッセツ
Czech Zlomenina bederního obratle
Korean 허리뼈의 골절
English Fracture of lumbar spine NOS, fractures lumbar vertebra, fracture lumbar spine, fracture of lumbar spine, Fracture;lumbar, fractures lumbar spine, fracture lumbar, lumbar fracture, lumbar vertebra fracture, fracture lumbar vertebra, fractures lumbar, Lumbar vertebral fracture, fracture of lumbar spine (diagnosis), Fracture of lumbar spine, Fracture of lumbar vertebra, Fracture of lumbar spine (disorder), fracture; lumbar spine, fracture; spine or vertebra, lumbar, lumbar; spine, fracture, spine or vertebra; fracture, lumbar, Lumbar Vertebral Fracture
Hungarian Lumbalis csigolyatörés
Spanish fractura de las vértebras lumbares, fractura de la columna vertebral lumbar (trastorno), fractura de la columna vertebral lumbar, Fractura de la vértebra lumbar
Dutch fractuur; lumbale wervelkolom, fractuur; wervel{kolom}, lumbaal, lumbaal; wervelkolom, fractuur, wervel{kolom}; fractuur, lumbaal, Fractuur van lumbale wervel, lendenwervelbreuk
Portuguese Fractura da vertebra lombar
French Fracture de vertèbre lombaire
German Fraktur eines Lendenwirbels

Ontology: Cauda Equina Syndrome (C0392548)

Definition (NCI) A rare neurologic disorder caused by impingement of the nerve roots of the cauda equina secondary to disc herniation, spinal stenosis, vertebral fracture, neoplasm or infection. Clinical signs may include bladder or bowel dysfunction, paresthesia and weakness of the lower extremities. The clinical course rapidly deteriorates and necessitates emergent surgical decompression to minimize risk of incontinence, sexual dysfunction and permanent paralysis.
Concepts Disease or Syndrome (T047)
MSH D011128
ICD9 344.6
ICD10 G83.4
SnomedCT 192973005, 89356000, 192972000, 155032006, 192970008
English Cauda equina syndrome NOS, cauda equina syndrome, cauda equina syndrome (diagnosis), Cauda Equina Syndromes, Syndrome, Cauda Equina, Syndromes, Cauda Equina, lumbosacral syndrome, syndrome cauda equina, Cauda equina syndrome NOS (disorder), Lumbosacral syndrome, Polyneuritis equi, Cauda equina neuritis, Cauda equina syndrome, Cauda equina syndrome (disorder), cauda equina; syndrome, syndrome; cauda equina, Cauda equina syndrome, NOS, Cauda equina syndrome (disorder) [Ambiguous], Cauda Equina Syndrome
Italian Cauda Equina, Sindrome lombo-sacrale
Dutch lumbosacraal syndroom, cauda equina; syndroom, syndroom; cauda equina, cauda equina syndroom, Cauda-equinasyndroom
French Syndrome lombosacré, Syndrome de la queue de cheval
German Lumbosakralsyndrom, Cauda-equina-Syndrom, Cauda- (equina-) Syndrom, Cauda equina Syndrome
Portuguese Síndrome lombossagrada, Síndrome da Cauda Equina, Síndrome da cauda equina
Spanish Síndrome lumbosacro, Síndrome de Cauda Equina, síndrome de la cola de caballo, SAI (trastorno), síndrome de la cola de caballo, SAI, síndrome de la cauda equina, SAI, síndrome de la cauda equina, síndrome de la cola de caballo (concepto no activo), síndrome de la cola de caballo (trastorno), síndrome de la cola de caballo, Síndrome de cauda equina
Japanese 馬尾症候群, 腰仙部症候群, ヨウセンブショウコウグン, バビショウコウグン
Czech Syndrom cauda equina, Lumbosakrální syndrom, syndroma caudae equinae, syndrom caudae equinae, syndrom kaudy
Korean 말총증후군
Hungarian Cauda equina syndroma, Lumbosacralis syndroma
Norwegian Cauda equina-syndrom

Ontology: Infection of lumbar spine (C0410372)

Concepts Disease or Syndrome (T047)
SnomedCT 203219002
English Infection of lumbar spine, Infection of lumbar spine (disorder)
Spanish infección de la columna vertebral lumbar (trastorno), infección de la columna vertebral lumbar

Ontology: Secondary malignant neoplasm of vertebral column (C0684550)

Definition (NCI) The spread of the cancer to the spine. This may be from a primary spinal cancer, or from a cancer at a distant site.
Concepts Neoplastic Process (T191)
SnomedCT 94602001
Italian Metastasi alla colonna vertebrale, Metastasi vertebrali
English Metastatic Neoplasm to the Spine, Metastatic Malignant Neoplasm to the Spine, vertebral metastasis (diagnosis), vertebral metastasis, Metastases to spine, Spinal secondaries, metastasis to spine, spine metastases, metastasis spine, spine metastasis, spinal metastases, secondary malignant neoplasm of vertebral column (diagnosis), secondary malignant neoplasm of vertebral column, bone neoplasm, malignant - vertebral column secondary, Spinal metastases, CA - Secondary cancer of spine, Secondary cancer of spine, Metastasis to vertebral column, Metastasis to spine, Secondary tumor of spine, Secondary tumour of spine, Metastatic malignant neoplasm to spine, Metastatic malignant neoplasm to vertebral column, Secondary malignant neoplasm of spine, Secondary malignant neoplasm of vertebral column (disorder), Secondary malignant neoplasm of vertebral column, Metastatic malignant neoplasm to vertebral column, NOS, Secondary malignant neoplasm of vertebral column, NOS, Metastatic malignant neoplasm to spine, NOS, Secondary malignant neoplasm of spine, NOS, Metastases to Spine, Metastases to the Spine, Metastasis to Spine, Metastasis to the Spine, Metastatic Cancer to the Spine, Metastatic Cancer to the Vertebral Column, Metastatic Neoplasm to the Vertebral Column, Metastatic Tumor to the Spine, Metastatic Tumor to the Vertebral Column
Dutch ruggenmergmetastase, ruggenmerg secondaries, wervelkolommetastasen
French Métastases rachidiennes, Tumeurs secondaires rachidiennes, Métastases vertébrales
German Wirbelsaeulen sekundaere, Wirbelsaeulenmetastasen
Portuguese Metástases espinhais, Metástases na coluna vertebral
Spanish Tumores secundarios vertebrales, neoplasia espinal metastásica maligna, neoplasia espinal secundaria maligna, neoplasia maligna secundaria de la columna vertebral (trastorno), neoplasia maligna secundaria de la columna vertebral, neoplasia metastásica maligna de la columna vertebral, Metástasis en la columna vertebral
Japanese 脊椎転移, セキツイテンイ
Czech Metastázy do páteře, Páteřní metastázy
Hungarian Gerincmetastasisok, Gerincáttétek, Gerinc metastasisok