Common Back Pain Red Flags

Is Your Back Pain a Sign of a Serious Disease?

There are times when the presence of back pain is a signal that something serious is going on with your health.  While your initial medical exam may not pinpoint the exact problem, it can lead the way to a timely diagnosis - and treatment - of issues such as cancer, infection, extreme (and ultra-debilitating) spinal problems and more.  

 "Red flags" are those signs and symptoms that may indicate to your doctor you have an underlying medical condition.

Below are a few of the most common red flags for which spine doctors generally screen during a medical evaluation.

Spinal Tumor or Cancer

Doctors preparing patient for MRI scan
Doctors preparing patient for MRI scan. Morsa Images / Getty Images

Information gleaned from your medical history - i.e.,  the interview you have with your doctor at the beginning of your appointment - may help her detect a spinal tumor or cancer, if either is there.  

Factors such as your age (are you over 50, or under 20, for example), if you've had cancer in the past, if you have severe pain, especially at night, if you've lost weight recently without trying, and/or if your pain gets worse when you lie on your back are all potential clues to this red flag.

Clearly, if your doctor expresses concern about cancer at your spine appointment, it's only a starting point.  Most likely she will refer you to another specialist for further testing.  

Spinal Infection

Stiff neck
Stiff neck. JGI/Tom Grill/Blend Images/Getty Images

Spinal infection is another red flag included in the medical history taken by your doctor.

If you are an IV drug user, have a compromised immune system (from HIV, steriod use or a transplant) and/or have had a urinary infection, you may be at a higher risk for a spinal infection.

Related: Inflammatory Granuloma

Types of infections include: Bacterial or viral infections, such as meningitis, fungal infections, infection in the epidural space around your spinal cord and surgery-related infection.

Related: The Fungal Meningitis Outbreak of Late 2012

Common symptoms indicating possible spinal infection include, but are not limited to, fever, chills, stiff neck and/or unexplained weight loss.  Rather than using these symptoms to diagnose yourself, though, be sure to communicate them thoroughly and honestly to your doctor.  This will allow her to detect any infection that may be present in your system - which may in turn save your life.

With a spinal infection, it is imperative to get an accurate diagnosis as quickly as you can. Treatment focuses on eliminating the infection, relieving pain, improving nutrition, maintaining spinal stability and preserving/restoring the functioning of your nervous system.

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Vertebral Fracture

Vertebral fracture.
Vertebral compression fracture. BSIP/UIG/Universal Images Group/Getty Images

As I mentioned above, some of the more serious back conditions also have red flags associated with their detection.  This means that certain aspects of your medical history and/or current symptoms may lead your doctor to suspect your pain is related to a fracture of one or more spinal bones.

Vertebral fracture is the most common serious condition assessed using red flags, according to Henschke, et. al, authors of a 2009 journal article entitled "Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain."  Their work was published in the January 31, 2013 edition of the Cochrane Database System Review.  

Major or minor, trauma can lead to spinal fracture, especially if you are elderly or you have (or are at risk for) osteopenia or osteoporosis.  During the medical interview with your doctor, it's best to divulge any and all information regarding motor vehicle accidents, falls or other physical trauma that has impacted your spine.  

Related:  Tips for Preventing Falls 

The Sydney researchers looked at 8 studies and found that using a single red flag is not a reliable way to diagnose a spinal fracture.  The researchers say that screening with just one red flag does not provide enough data for accurately determining the likelihood of spinal fracture occurrences.  

And, although it's an improvement, the researchers say that the evidence for using a combination of red flags to determine if you have a spinal fracture is weak.

The Cochrane researchers also note that red flags for spinal fracture can be associated with false positive results.  They caution that acting on information from a red flag screening without researching and considering (in tandem with your health provider, I hope!) your best course of action may cost you a lot, but not deliver satisfactory pain relief.

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Cauda Equina Syndrome

The nerves of the lower back
The nerves of the lower back. / Getty Images

In a perfect world, the emergency room is reserved for extreme symptoms and spine-related disorders.  One such disorder is cauda equina syndrome.

Cauda equina syndrome can result in serious damage to your health - including paralysis and other outcomes.  As such, symptoms of cauda equina warrant immediate medical attention.

These symptoms are also the red flags your doctor may pick up from your medical history.  They include:

  • Saddle anesthesia, which is nerve related symptoms in the area of your seat.  (Saddle anesthesia is technically called  focal neurological defect.)  The symptoms you'll likely notice include numbness located at the bottom of the pelvis and around the area of your seat.
  • Bladder or bowel problems, especially recent onset of urinary retention  (inability to urinate),  increased frequency of urination and/or overflow incontinence.  
  • Weakness and/or sciatica, especially if it is severe or keeps getting worse.  

The results of your physical exam may also provide clues to your doctor regarding the presence of cauda equina syndrome.

Making Sense of Red Flag Information

Lower Back, Lumbar Pain
Lower Back, Lumbar Pain. Universal Images Group / Getty Images

As you can see, red flags often indicate a serious underlying medical condition. 

Because of this, it's best to speak with your doctor about any findings.  This is so even if the  screening was performed by your physical therapist, personal trainer or holistic practitioner. 

Again, red flag findings generally represent the beginning of an(other) health odyssey.  If one or more are found during your exam, most likely you can expect more evaluations, tests and possibly treatments.


Bratton, R., MD, Assessment and Management of Acute Low Back Pain. Am Fam Physician. 1999 Nov 15;60(8):2299-2306.

Deane, K. Acute Low Back Pain in Primary Care -- How Good Are "Red Flags" at Identifying Serious Abnormalities? Jan 28, 2010

Ferguson F, Holdsworth L, Rafferty D. Low back pain and physiotherapy use of red flags: the evidence from Scotland. Physiotherapy. 2010 Dec;96(4):282-8.

Henschke N, Maher CG, Ostelo RW, de Vet HC, Macaskill P, Irwig L., Red flags to screen for malignancy in patients with low-back pain. Cochrane Database Syst Rev. 2013. Feb 28.
Henschke N, Maher CG, Refshauge KM. A systematic review identifies five "red flags" to screen for vertebral fracture in patients with low back pain. J Clin Epidemiol. 2008 Feb;61(2):110-118.

Leerar PJ, Boissonnault W, Domholdt E, Roddey T. Documentation of red flags by physical therapists for patients with low back pain. J Man Manip Ther. 2007;15(1):42-9.

Williams CM, Henschke N, Maher CG, van Tulder MW, Koes BW, Macaskill P, Irwig L. Red flags to screen for vertebral fracture in patients presenting with low-back pain. Cochrane Database Syst. Rev. 2013. Jan 31.

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