Red flags & spinal emergencies

What is a red flag in musculoskeletal assessment?

An indicator of potential serious underlying pathology.

List key red flags for lumbar spine assessment.

Bladder/bowel dysfunction, saddle anesthesia, loss of power/sensation (especially bilateral), recent trauma, fever, weight loss, night pain, history of malignancy, progressive neurological deficit.

What serious conditions do red flags aim to detect?

Cauda equina syndrome (CES), spinal fracture, malignancy, spinal infection.

What is cauda equina syndrome (CES)?

Compression of the nerve roots below the conus medullaris, causing loss of bowel/bladder control, saddle anesthesia, and lower limb weakness.

What is the prevalence of serious spinal pathology in back pain populations?

Rare—about 1% of total back pain cases (CSAG 1994).

How many people with acute low back pain present with at least one red flag?

80% (from patient history or initial examination).

What is the importance of recognizing red flags?

Early identification for urgent referral, potential avoidance of permanent neurological damage.

What is saddle anesthesia?

Loss of sensation in the perineal area, e.g., inner thighs, buttocks, genital region.

Why is recent trauma a critical red flag in older adults?

Increased risk of vertebral fracture due to osteoporosis.

What is spinal cord compression?

Pressure on spinal cord/nerves from injury, tumor, or abscess; urgent surgical or oncology assessment needed.

What infections affect the spine?

Discitis, vertebral osteomyelitis, epidural abscess.

How to manage a suspected spinal emergency?

Immediate referral to emergency services/medical team for MRI and specialist review.

Why is bladder dysfunction concerning in spinal assessment?

Retention or incontinence can indicate CES or spinal cord compression; urgent investigation required.

What are consequences of missing red flags?

Delayed diagnosis, risk of irreversible neurological loss or death.

Cauda Equina Syndrome (CES):

• Unilateral leg symptoms progressing to bilateral

• Reduced perianal/saddle sensation (loss, pins & needles, numbness between thighs or genitals)

• Altered bladder function (retention, overflow incontinence, leaking, reduced sensation passing urine, not knowing when bladder is full/empty)

• Bowel disturbance (loss of sensation during bowel movement, leaking, incontinence, inability to control movement)

• Reduced anal sphincter tone (loss of squeeze, change in ability)

• Sexual dysfunction (erectile/ejaculatory problems, loss of sensation during intercourse)

• Progressive loss of motor/sensory function in lower limbs

• New or changing motor weakness (unilateral → bilateral)

• Age (<50 and disc herniation), history of disc disease or spinal surgery

Malignancy/Metastatic Spinal Cord Compression (MSCC):

• History of cancer, especially breast, prostate, lung, or myeloma

• New or escalating non-mechanical pain (especially thoracic), band-like or multi-segmental pain

• Pain severe or progressive, unresponsive to medication

• Night pain/disturbed sleep due to pain

• Unexplained weight loss (5% over 6-12 months)

• Age >50

• General malaise/fatigue

• New or unexplained neurological deficit (weakness, sensory loss, loss of coordination, gait disturbance)

• Structural deformity, new severe kyphosis

• Lying flat increases pain

• Agonising pain causing anguish

• Recent onset bladder/bowel symptoms

• Known metastases, previous history of cancer

• Early warning: heavy legs, odd sensations, inability to sleep on back (thoracic flag), gait disturbance

Spinal Fracture (Osteoporotic/Trauma):

• Recent low-impact trauma (fall, slip, minor lift, especially in flexion)

• Female gender, age >50 (increased risk)

• Postmenopausal osteoporosis, family history

• Previous history of fracture or corticosteroid use (≥7.5 mg for ≥3 months)

• Sudden onset severe thoracolumbar pain, especially unfamiliar pain

• Tenderness over spinal processes, increased kyphosis, structural deformity

• Limited mobility, severe pain on weight-bearing

• Severe trauma (fall from height), immediate onset pain

• Previous history of cancer, suspected metastatic bone disease

Spinal Infection (Discitis/Osteomyelitis/Epidural Abscess):

• Insidious onset spinal pain, non-mechanical character

• Neurological symptoms: new sensory/motor deficit, fatigue

• Fever, unexplained weight loss

• Known immunosuppression (HIV/AIDS, diabetes, RA, long-term steroids)

• Alcohol abuse, intravenous drug use, occupational exposure, homelessness, migrant status

• Recent spinal surgery/procedure, pre-existing bacterial infection (e.g. UTI)

• Discitis (lumbar > thoracic > cervical), TB history

• Penetrating wound, previous back surgery

• Significant past medical history, poor appetite, rapid fatigue

Inflammatory Arthritis:

• Morning stiffness >30 minutes

• Younger age at onset (<40 years)

• Insidious onset, improvement with exercise

• Alternating buttock pain

General Red Flag Features (all conditions):

• Pain at night

• Continuous pain

• Pain >1 month duration without improvement despite treatment

• Elevated ESR/CRP (if assessed)

• Older age (>50)

• Unexplained/unintentional weight loss

• Structural deformity or progressive neurological change