Back pain (red flags): Difference between revisions
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==General== | ==General== | ||
Although there are many red flags of back pain on history and physical, meta-analysis has | Although there are many red flags of back pain on history and physical, meta-analysis has shown the following to be predictive of fracture or malignancy: | ||
{{Back pain red flags}} | {{Back pain red flags}} | ||
| Line 7: | Line 7: | ||
*Pain >6wk (tumor, infection) | *Pain >6wk (tumor, infection) | ||
*Age >50 or <18 (tumor, congenital anomaly) | *Age >50 or <18 (tumor, congenital anomaly) | ||
*History of trauma | *History of [[trauma]] | ||
*History of IVDU | *History of [[IVDU]] | ||
*History of cancer | *History of cancer | ||
*History of sciatica | *History of sciatica | ||
*Neurological complaints (paresthesias, anesthesia, weakness) | *Neurological complaints ([[paresthesias]], [[numbness|anesthesia]], [[weakness]]) | ||
*Urinary retention | *[[Urinary retention]] | ||
*Incontinence of bowel/bladder | *[[urinary incontinence|Incontinence]] of bowel/bladder | ||
*Night pain | *Night pain | ||
*Unremitting pain, even when supine | *Unremitting pain, even when supine | ||
*Fever, chills, night sweats | *[[Fever]], chills, night sweats | ||
*Anticoagulants/coagulopathy | *[[Anticoagulants]]/[[coagulopathy]] | ||
===Physical Exam=== | ===Physical Exam=== | ||
*Fever | *[[Fever]] | ||
*Patient writhing in pain | *Patient writhing in pain | ||
*Anal sphincter laxity | *Anal sphincter laxity | ||
| Line 26: | Line 26: | ||
*Palpable bladder post voiding or [[Urinary retention|abnormal post void residual]] | *Palpable bladder post voiding or [[Urinary retention|abnormal post void residual]] | ||
*Point vertebral tenderness | *Point vertebral tenderness | ||
*Neurological deficits | *[[focal neuro deficits|Neurological deficits]] | ||
*Positive straight leg raise | *Positive straight leg raise | ||
| Line 47: | Line 47: | ||
*Immunocompromised state | *Immunocompromised state | ||
**[[HIV]] | **[[HIV]] | ||
**Systemic corticosteroids | **Systemic [[corticosteroids]] | ||
**[[Transplant complications|Transplant]] | **[[Transplant complications|Transplant]] | ||
**[[Diabetes Mellitus|DM]] | **[[Diabetes Mellitus|DM]] | ||
| Line 55: | Line 55: | ||
*Saddle anesthesia | *Saddle anesthesia | ||
*Decreased anal sphincter tone | *Decreased anal sphincter tone | ||
*Bilateral lower extremity weakness or numbness | *Bilateral lower extremity [[weakness]] or [[numbness]] | ||
*Neurologic deficit | *Neurologic deficit | ||
| Line 71: | Line 71: | ||
*Bony tenderness | *Bony tenderness | ||
===[[AAA]]=== | ===[[AAA]]/[[Nontraumatic thoracic aortic dissection|Aortic Dissection]]=== | ||
*Risk factors for PVD | *Risk factors for PVD | ||
*Pulsating mass | *Pulsating mass | ||
Latest revision as of 04:59, 3 February 2021
General
Although there are many red flags of back pain on history and physical, meta-analysis has shown the following to be predictive of fracture or malignancy:
Back Pain Risk factors and probability of Fracture or Malignancy[1]
| Factor | Post Test Probability (95%CI) |
| Older Age (>65yo) | 9% (3-25%) |
| Prolonged corticosteroid | 33% (10-67%) |
| Severe trauma | 11% (8-16%) |
| Presence of contusion or abrasion | 62% (49-74%) |
| Multiple red flags | 90% (34-99%) |
| History of malignancy | 33% (22-46%) |
Red Flag Symptoms of Low Back Pain [2]
| Symptoms | Corresponding Pathology |
|---|---|
| Age under 18 years | Congenital abnormality |
| Age over 50 years | Fracture, malignancy |
| Anticoagulant use | Spinal hematoma |
| Fever | Infection, malignancy |
| Genitourinary issues including urinary retention/incontinence or sexual dysfunction | Cauda equina syndrome |
| Immunocompromised | Fracture, infection |
| IV drug use | Infection |
| Recent spinal surgery or epidural injection | Infection, spinal hematoma |
| Trauma | Fracture, spinal hematoma |
Red Flag Signs of Low Back Pain[3]
| Signs | Corresponding Pathology |
|---|---|
| Reduced anal sphincter tone | Cauda equina syndrome |
| Hyperreflexia | Acute cord compression |
| Hyporeflexia/areflexia | Cauda equina syndrome |
| Lower extremity muscle weakness | Acute cord compression or Cauda equina syndrome |
| Saddle paresthesia/anesthesia | Cauda equina syndrome |
| Absent or decreased bulbocavernosus reflex | Cauda equina syndrome |
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/Aortic Dissection
- Risk factors for PVD
- Pulsating mass
- Pain at rest or at night
- Age >60yrs
See Also
References
- ↑ Downie A, et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ. 2013; 347:f7095. [1]
- ↑ Depalma. Red flags of low back pain. JAAPA. 2020;33(8):8. doi:10.1097/01.JAA.0000684112.91641.4c
- ↑ Depalma. Red flags of low back pain. JAAPA. 2020;33(8):8. doi:10.1097/01.JAA.0000684112.91641.4c