Red flags

In early management of low back pain (LBP) the identification of “red flags” (RFs) plays an important role, as this condition is highly prevalent, and advanced treatment would not be feasible in every case. These alarm signs are designed to detect serious causes requiring prompt interventions, such as malignancy, fracture, inflammation, or cauda equina syndrome. Although their predictive value has been questioned, they are commonly used in clinical practice ¹⁾.

● age >70 years, or <20 yrs

● systemically ill patients

● temp >100°F (or >38° C)

● history of malignancy

● recent infection

● patients with neurologic deficits suggesting possible cauda equina syndrome (saddle anesthesia, urinary incontinence or retention, LE weakness)

● heavy alcohol or IV drug abusers

● diabetics

● immunosuppressed patients (including prolonged treatment with corticosteroids)

● recent urinary tract or spinal surgery

● recent trauma: any age with significant trauma, or >50 yrs old with mild trauma

● unrelenting pain at rest

● persistent pain for more than ≈ 4 weeks

● unexplained weight loss

Cancer or infection:

Age > 50 years or < 20 years.

History of cancer.

Unexplained weight loss.

Immunosuppression.

Urinary tract infection, IV drug abuse, fever or chills.

Back pain not improved with rest.

Spinal fracture:

History of significant trauma.

Prolonged use of steroids.

Age > 70 yrs

Cauda equina syndrome or severe neurologic compromise:

Acute onset of urinary retention or overflow urinary incontinence.

Fecal incontinence or loss of anal sphicter tone

Saddle anesthesia.

Global or progressive weakness in the lower extremities.

Imaging is important in the evaluation of patients with degenerative disease and infectious processes. There are numerous conditions that can manifest as low back pain (LBP) or neck pain in a patient, and in many cases, the cause may be multifactorial.

Clinical history and physical examination are key components in the evaluation of such patients; however, physical examination has variable sensitivity and specificity. Although studies have demonstrated that uncomplicated acute LBP and/or radiculopathy are self-limited conditions that do not warrant any imaging, neuroimaging can provide clear anatomic delineation of potential causes of the patient's clinical presentation. Various professional organizations have recommendations for imaging of LBP, which generally agree that an imaging study is not indicated for patients with uncomplicated LBP or radiculopathy without a red flag (eg, neurological deficit such as major weakness or numbness in lower extremities, bowel or bladder dysfunction, saddle anesthesia, fever, history of cancer, intravenous drug use, immunosuppression, trauma, or worsening symptoms). Different imaging modalities have a complementary role in the diagnosis of pathologies affecting the spine.