Back pain (red flags)

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Although there are many red flags of back pain on history and physical, meta-analysis has shown 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


Physical Exam

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

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/Aortic Dissection

  • Risk factors for PVD
  • Pulsating mass
  • Pain at rest or at night
  • Age >60yrs

See Also


  1. 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]
  2. Depalma. Red flags of low back pain. JAAPA. 2020;33(8):8. doi:10.1097/01.JAA.0000684112.91641.4c
  3. Depalma. Red flags of low back pain. JAAPA. 2020;33(8):8. doi:10.1097/01.JAA.0000684112.91641.4c