II. Precautions
- Low back red flag check lists have poor Test Specificity
- Many patients with Low Back Pain have at least one red flag (>80%)
- Evaluate red flags in the context of the clinical presentation as a whole
- Keep a high index of suspicion in high risk patients or where more than one red flag is present
- Positive red flags are typically indications for imaging
III. Red Flags: Summary (Mnemonic: TUNA FISH, as an aid to documentation)
- T - Trauma
- U - Unexplained Weight Loss
- N - Neurologic findings (includes bowel or bladder Incontinence and other Cauda Equina Syndrome symptoms)
- A - Age >55 years (or age >65 years)
- F - Fever
- I - Immunocompromised
- S - Steroids
- H - History of HIV, Tuberculosis, Cancer
- References
- Mallon (2019) CCME EM Board Review, Las Vegas, accessed 8/1/2019
IV. Red Flags: Cancer Related Red Flags with Low Back Pain
- See Spinal Neoplasm
- History of cancer (esp. recent)
- Unexplained Weight Loss >10 kg within 6 months
- Age over 50 years or under 18 years old
- Failure to improve with therapy
- Pain persists for more than 4 to 6 weeks
- Night pain or pain at rest
V. Red Flags: Infection Related Red Flags with Low Back Pain
- See Spinal Infection (Spinal Osteomyelitis, Spinal Epidural Abscess, Discitis)
- Persistent fever (Temperature over 100.4 F)
- Poor Test Sensitivity for Spinal Infection
- History of Intravenous Drug Abuse
- Severe Pain
- Lumbar Spine Surgery within the last year
- Epidural Anesthesia
- Recent Bacterial Infection
- Urinary Tract Infection or Pyelonephritis
- Cellulitis
- Pneumonia
- Wound (e.g. Decubitus Ulcer) in spine region
- Dental Abscess
- Endocarditis
- Sepsis
-
Immunocompromised states
- Systemic Corticosteroids
- Organ transplant
- Diabetes Mellitus
- Human Immunodeficiency Virus (HIV)
- Rest Pain
VI. Red Flags: Cauda Equina Syndrome Related Red Flags with Back Pain
- See Cauda Equina Syndrome
- Urinary Incontinence or retention
- Saddle Anesthesia
- Anal sphincter tone decreased or Fecal Incontinence
- Bilateral lower extremity weakness or numbness
- Progressive neurologic deficit
- Major motor weakness
- Major sensory deficit
VII. Red Flags: Significant Herniated nucleus pulposus
- Major Muscle Weakness (strength 3 of 5 or less)
- Foot Drop
VIII. Red Flags: Vertebral Fracture related red flags with Low Back Pain
- See Thoracolumbar Trauma
- See Vertebral Compression Fracture
- Prolonged use of Corticosteroids
- Age greater than 70 years
- History of Osteoporosis
- Mild Trauma over age 50 years (or with Osteoporosis)
- Recent significant Trauma at any age
- Ejection from motor vehicle
- Fall from substantial height
IX. Red Flags: Abdominal Aortic Aneurysm red flags with Low Back Pain
- Risk Factors (males over age 65 years with a history of Tobacco Abuse)
- Abdominal pulsating mass
- Atherosclerotic vascular disease
- Pain at rest or nocturnal pain
- Renal Colic presentation without a history of known aneurysm
X. Red Flags: General (weak Test Specificity)
- Vertebral tenderness
- Limited spine range of motion
XI. References
- Cali and Bond (2022) Crit Dec Emerg Med 36(7): 4-11
- Atlas (2001) J Gen Intern Med 16:123 [PubMed]
- Henschke (2009) Arthritis Rheum 60(10): 3072-80 [PubMed]
- Petri (1999) Emerg Med Clin North Am 17:25-39 [PubMed]
- Swenson (1999) Neurol Clin 17:43-63 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
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 |
Russian | RADIKULIT POIASNICHNYI, LIUMBAGO, POIASNICHNYI RADIKULIT, ЛЮМБАГО, ПОЯСНИЧНЫЙ РАДИКУЛИТ, РАДИКУЛИТ ПОЯСНИЧНЫЙ |
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 |
Croatian | BOL U KRIŽIMA, KRIŽOBOLJA |
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 |
Russian | ANEVRIZMA AORTY BRIUSHNOI, AORTY BRIUSHNOI ANEVRIZMA, АНЕВРИЗМА АОРТЫ БРЮШНОЙ, АОРТЫ БРЮШНОЙ АНЕВРИЗМА |
Czech | Aneurysma břišní aorty, Břišní aneurysma, aorta abdominalis - aneurysma, aneurysma abdominalní aorty |
Polish | Tętniak aorty brzusznej |
Croatian | AORTNA ANEURIZMA, ABDOMINALNA |
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 |