TABLE 2741 Red Flags for Potentially Serious Conditions

AHCPR classifies low back problems into working categories:

Potentially serious spinal condition—tumor, infection, spinal fracture, or a major neurologic compromise, such as cauda equina syndrome, suggested by a red flag. Sciatica—back-related lower limb symptoms suggesting lumbosacral nerve root compromise.

Nonspecific back symptoms—occurring primarily in the back and suggesting neither nerve root compromise nor a serious spinal condition.

Objectives of the diagnostic process are to rule out a serious systemic disease and neurologic compromise by searching for "red flags" for spine fracture, tumor, infection, cauda equina syndrome, or nonspinal pathology. Given the many variables impacting onset and persistence of back problems, one must also assess social or psychological distress (nonphysical factors) that may amplify or prolong pain. 16

If a potentially dangerous problem is not present, diagnostic testing in the first 4 weeks of symptoms is not helpful. Ultimately, the treatment goal is to improve activity tolerance rather than focus on pain. Evaluation and treatment algorithms and tables are provided within the guideline to assist in initial and follow-up assessment of patients. A patient's estimate of personal activity intolerance due to low back symptoms contributes to the clinical assessment of the severity of the back problem, guides treatment, and establishes a baseline for recommending daily activities and evaluating progress. 15

Spinal fracture may be suspected in major trauma, such as motor vehicle accident or fall from height, or minor trauma, or even strenous lifting in an older or potentially osteoporotic patient. The examiner must give credence to the history, age, and circumstances of onset in establishing a diagnosis. For example, an elderly woman with acute onset, severe midthoracic pain, without a history of trauma, can be presumed to have an osteoporotic vertebral compression fracture until proved otherwise. Sacral insufficiency fractures may also be considered in elderly women.17 Compression fracture is increasingly likely in patients over age 50 and more so for those over 70 years old. History of trauma or steroid use also supports this in the differential diagnosis (see Table... .2.7.4-1).

Less than 1 percent of patients presenting to a general medical clinic with low back pain (LBP) had cancer. 16 All patients with cancer-related LBP had at least one of the following: age 350 (80 percent); previous history of breast, lung, or prostate cancer (33 percent); unexplained weight loss, fever, chills; failure of conservative therapy; no relief with bedrest or supine position; and pain duration >1 month. Percussion pain over the bony spine itself supports the presence of an osseous abnormality, such as compression fracture, metastasis, or disk or vertebral infection.18

In patients found to have a spinal infection, fever was only associated 27 percent of the time. Other factors that raise the suspicion of infection are IV drug use, urinary tract infection, skin infection, and immune suppression due to steroids, transplant, or HIV. Disk space infections are relatively uncommon and are most often associated with recent disk surgery. However, they can also occur in association with a remote infection, that is, kidney, skin, distal trauma to a bursa, or in the drug addicted, or can also arise spontaneously in rare cases.18

The onset of lumbosacral pain associated with bilateral leg pain radiation and a sudden loss of bladder control should be presumed to be a midline herniated disk with the threat of paraparesis (cauda equina syndrome). This demands careful neurologic exam including rectal examination for sensory changes ("saddle anesthesia"), examination for motor and reflex function, and examination for possible immediate consultation for emergent imaging and possibly surgical intervention.

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