Back pain (red flags): Difference between revisions
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===History=== | ===History=== | ||
*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=== | ===Physical Exam=== | ||
*Fever | |||
*Patient writhing in pain | |||
*Anal sphincter laxity | |||
*Perianal/perineal sensory loss (Saddle Anesthesia) | |||
*Palpable bladder post voiding or [[Urinary retention|abnormal post void residual]] | |||
*Point vertebral tenderness | |||
*Neurological deficits | |||
*Positive straight leg raise | |||
==Specific Condition Red Flags== | ==Specific Condition Red Flags== | ||
===Cancer Related=== | ===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=== | ===Infection Related=== | ||
*Persistent fever | |||
*History of IVDA | |||
*Recent infection | |||
*Immunocompromised state | |||
**[[HIV]] | |||
**Systemic corticosteroids | |||
**[[Transplant complications|Transplant]] | |||
**[[Diabetes Mellitus|DM]] | |||
===[[Spinal cord compression (non-traumatic)|Cauda Equina]]=== | ===[[Spinal cord compression (non-traumatic)|Cauda Equina]]=== | ||
*Incontinence or [[Urinary retention|retention]] | |||
*Saddle anesthesia | |||
*Decreased anal sphincter tone | |||
*Bilateral lower extremity weakness or numbness | |||
*Neurologic deficit | |||
===Herniated Disc=== | ===Herniated Disc=== | ||
*Muscle Weakness | |||
*Radiation of pain | |||
*Footdrop | |||
===[[Vertebral fractures|Vertebral Fracture]]=== | ===[[Vertebral fractures|Vertebral Fracture]]=== | ||
*Prolonged use of corticosteroids | |||
*History of osteoporosis | |||
*Age>70 | |||
*Mild trauma in age >50yr | |||
*Significant trauma in any age | |||
*Bony tenderness | |||
===[[AAA]]=== | ===[[AAA]]=== | ||
*Risk factors for PVD | |||
*Pulsating mass | |||
*Pain at rest or at night | |||
*Age >60yrs | |||
==See Also== | ==See Also== | ||
Revision as of 21:42, 25 April 2017
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 (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%) |
Red Flag Symptoms of Low Back Pain [2]
| Symptoms | Corresponding Pathology |
|---|---|
| Age under 18 years | Congenital abnormality |
| Age over 50 years | Fracture, malignancy |
| Anticoagulant use | Spinal hematoma |
| Fever | Infection, malignancy |
| Genitourinary issues including urinary retention/incontinence or sexual dysfunction | Cauda equina syndrome |
| Immunocompromised | Fracture, infection |
| IV drug use | Infection |
| Recent spinal surgery or epidural injection | Infection, spinal hematoma |
| Trauma | Fracture, spinal hematoma |
Red Flag Signs of Low Back Pain[3]
| Signs | Corresponding Pathology |
|---|---|
| Reduced anal sphincter tone | Cauda equina syndrome |
| Hyperreflexia | Acute cord compression |
| Hyporeflexia/areflexia | Cauda equina syndrome |
| Lower extremity muscle weakness | Acute cord compression or Cauda equina syndrome |
| Saddle paresthesia/anesthesia | Cauda equina syndrome |
| Absent or decreased bulbocavernosus reflex | Cauda equina syndrome |
History
- 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
- HIV
- Systemic corticosteroids
- Transplant
- DM
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
AAA
- Risk factors for PVD
- Pulsating mass
- Pain at rest or at night
- Age >60yrs
See Also
References
- ↑ 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]
- ↑ Depalma. Red flags of low back pain. JAAPA. 2020;33(8):8. doi:10.1097/01.JAA.0000684112.91641.4c
- ↑ Depalma. Red flags of low back pain. JAAPA. 2020;33(8):8. doi:10.1097/01.JAA.0000684112.91641.4c