Back pain (red flags)

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General

Although there are many red flags of back pain on history and physical, meta-analysis has show the following to be predictive of fracture or malignancy:

Back Pain Risk factors and probability of Fracture or Malignancy[1]
Factor Post Test Probability
Older Age (>65yo) 9%

(95% CI 3% to 25%)

Prolonged corticosteroid 33%

(95% CI 10% to 67%)

Severe trauma 11%

(95% CI 8% to 16%)

Presence of contusion or abrasion 62%

(95% CI 49% to 74%)

Multiple red flags 90%

(95% CI 34% to 99%)

Hx of malignancy 33%

(95% CI 22% to 46%)

History

  1. Pain >6wk (tumor, infection)
  2. Age >50 or <18 (tumor, congenital anomaly)
  3. History of trauma
  4. History of IVDU
  5. History of cancer
  6. History of sciatica
  7. Neurological complaints (paresthesias, anesthesia, weakness)
  8. Urinary retention
  9. Incontinence of bowel/bladder
  10. Night pain
  11. Unremitting pain, even when supine
  12. Fever, chills, night sweats
  13. Anticoagulants/coagulopathy

Physical Exam

  1. Fever
  2. Patient writhing in pain
  3. Anal sphincter laxity
  4. Perianal/perineal sensory loss (Saddle Anesthesia)
  5. Palpable bladder post voiding or abnormal post void residual
  6. Point vertebral tenderness
  7. Neurological deficits
  8. Positive straight leg raise

Specific Condition Red Flags

Cancer Related

  1. History of back pain
  2. Weight loss >10kg in 6mo
  3. Age >50 or <18
  4. No improvement despite therapy
  5. Pain for >4-6wks
  6. Night pain
  7. Pain worse at rest
  8. Vertebral tenderness
  9. Multiple nerve roots affected

Infection Related

  1. Persistent fever
  2. History of IVDA
  3. Recent infection
  4. Immunocompromised state
    1. HIV
    2. Systemic corticosteroids
    3. Transplant
    4. DM

Cauda Equina

  1. Incontinence or retention
  2. Saddle anesthesia
  3. Decreased anal sphincter tone
  4. Bilateral lower extremity weakness or numbness
  5. Neurologic deficit

Herniated Disc

  1. Muscle Weakness
  2. Radiation of pain
  3. Footdrop

Vertebral Fracture

  1. Prolonged use of corticosteroids
  2. History of osteoporosis
  3. Age>70
  4. Mild trauma in age >50yr
  5. Significant trauma in any age
  6. Bony tenderness

AAA

  1. Risk factors for PVD
  2. Pulsating mass
  3. Pain at rest or at night
  4. Age >60yrs

See Also

References

  1. 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]

Authors

Neil Young