When assessing a patient with spinal or limb pain, it is important to look for the presence of red flags, which may indicate serious underlying spinal pathology. If a serious condition is suspected, an urgent or emergency referral to your local spinal unit may be necessary, although a degree of clinical judgement is required when referring these cases.

Red Flags for Spinal Metastases

• Constant severe mechanical spinal pain
• Progressive spinal pain despite conservative treatment
• Persistent thoracic spine pain
• Patient age under 20 or over 50 with back pain for the first time
• Personal or family history of cancer
• Unexplained weight loss, cachexia, loss of appetite
• Structural deformity of spine

Red Flags for Spinal Infection

• Constant severe spinal pain which continues when supine. May worsen at night
• Unexplained fever, malaise or lethargy
• Recent bacteraemic infection, UTI, or endoscopic procedure
• Immune suppression risk factors: Diabetes, alcohol dependence, IV drug misuse or HIV
• Structural deformity of spine

Red Flags for Cauda Equina Syndrome

• Recent onset urinary retention with overflow incontinence
• Recent onset faecal incontinence
• Bilateral sciatica, leg numbness or weakness
• Progressive bilateral neurological deficit in the legs
• Perineal / saddle anaesthesia
• Lax anal sphincter

Red Flags for Spinal Fracture

• History of fall or spinal trauma
• History of osteoporosis
• Long-term steroid medication