Diagnostic triage for back pain
(including red flags)
The main diagnostic indicators for simple backache, nerve root pain and
possible serious spinal pathology ( ‘ red flags ’ )
are outlined below:
Simple backache
● Onset generally age 20–55 years
● Lumbosacral region, buttocks and thighs
● Pain mechanical in nature
– varies with physical activity
– varies with time
● Patient well
● Prognosis good (90% recover from acute attack in 6 weeks)
Nerve root pain
● Unilateral leg pain back pain
● Pain generally radiates to foot or toes
● Numbness and paraesthesia in the same distribution
● Nerve irritation signs
– reduced straight leg raising which reproduces leg pain
● Motor, sensory or reflex change
– limited to one nerve root
● Prognosis reasonable (50% recover from acute attack within 6 weeks)
Possible serious spinal pathology
Red flags
● Age of onset 20 or 55 years
● Violent trauma
● Constant, progressive, non-mechanical pain
● Thoracic pain
, ● Previous medical history – carcinoma
● Systemic steroids
● Drug abuse, HIV
● Systemically unwell
● Weight loss
● Persisting severe restriction of lumbar flexion
● Widespread neurology
● Structural deformity
If there are suspicious clinical features, or if pain has not settled in 6
weeks, an ESR and plain X-ray should be considered.
Cauda equina syndrome/widespread neurological
disorder
● Difficulty with micturition
● Loss of anal sphincter tone or faecal incontinence
● Saddle anaesthesia about the anus, perineum or genitals
● Widespread or progressive motor weakness in the legs or gait
disturbance
Inflammatory disorders (ankylosing spondylitis
and related disorders)
● Gradual onset
● Marked morning stiffness
● Persisting limitation of spinal movements in all directions
● Peripheral joint involvement
● Iritis, skin rashes (psoriasis), colitis, urethral discharge
● Family history
(including red flags)
The main diagnostic indicators for simple backache, nerve root pain and
possible serious spinal pathology ( ‘ red flags ’ )
are outlined below:
Simple backache
● Onset generally age 20–55 years
● Lumbosacral region, buttocks and thighs
● Pain mechanical in nature
– varies with physical activity
– varies with time
● Patient well
● Prognosis good (90% recover from acute attack in 6 weeks)
Nerve root pain
● Unilateral leg pain back pain
● Pain generally radiates to foot or toes
● Numbness and paraesthesia in the same distribution
● Nerve irritation signs
– reduced straight leg raising which reproduces leg pain
● Motor, sensory or reflex change
– limited to one nerve root
● Prognosis reasonable (50% recover from acute attack within 6 weeks)
Possible serious spinal pathology
Red flags
● Age of onset 20 or 55 years
● Violent trauma
● Constant, progressive, non-mechanical pain
● Thoracic pain
, ● Previous medical history – carcinoma
● Systemic steroids
● Drug abuse, HIV
● Systemically unwell
● Weight loss
● Persisting severe restriction of lumbar flexion
● Widespread neurology
● Structural deformity
If there are suspicious clinical features, or if pain has not settled in 6
weeks, an ESR and plain X-ray should be considered.
Cauda equina syndrome/widespread neurological
disorder
● Difficulty with micturition
● Loss of anal sphincter tone or faecal incontinence
● Saddle anaesthesia about the anus, perineum or genitals
● Widespread or progressive motor weakness in the legs or gait
disturbance
Inflammatory disorders (ankylosing spondylitis
and related disorders)
● Gradual onset
● Marked morning stiffness
● Persisting limitation of spinal movements in all directions
● Peripheral joint involvement
● Iritis, skin rashes (psoriasis), colitis, urethral discharge
● Family history
