Low Back Pain Red Flag

Aka: Low Back Pain Red Flag, Serious Low Back Symptoms, Low Back Pain suggestive of Spinal Fracture, Low Back Pain Suggestive of Cancer, Low Back Pain Suggestive of Infection, Low Back Pain Suggestive of Neurologic Injury, Low Back Pain Suggestive of Aortic Aneurysm

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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

  1. See Spinal Infection (Spinal Osteomyelitis, Spinal Epidural Abscess, Discitis)
  2. Persistent fever (Temperature over 100.4 F)
    1. Poor Test Sensitivity for Spinal Infection
  3. History of Intravenous Drug Abuse
  4. Severe Pain
  5. Lumbar Spine Surgery within the last year
  6. Epidural Anesthesia
  7. Recent Bacterial Infection
    1. Urinary Tract Infection or Pyelonephritis
    2. Cellulitis
    3. Pneumonia
    4. Wound (e.g. Decubitus Ulcer) in spine region
    5. Dental Abscess
    6. Endocarditis
    7. Sepsis
  8. Immunocompromised states
    1. Systemic Corticosteroids
    2. Organ transplant
    3. Diabetes Mellitus
    4. Human Immunodeficiency Virus (HIV)
    5. Rest 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

XI. References

  1. Cali and Bond (2022) Crit Dec Emerg Med 36(7): 4-11
  2. Atlas (2001) J Gen Intern Med 16:123 [PubMed]
  3. Henschke (2009) Arthritis Rheum 60(10): 3072-80 [PubMed]
  4. Petri (1999) Emerg Med Clin North Am 17:25-39 [PubMed]
  5. Swenson (1999) Neurol Clin 17:43-63 [PubMed]

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