Back pain (red flags)

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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%)


  • 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

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


  • Risk factors for PVD
  • Pulsating mass
  • Pain at rest or at night
  • Age >60yrs

See Also


  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]


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