A Question A Day (W5D6)

1. Red flags are clinical indicators of possible serious underlying conditions requiring further
medical intervention (require urgent attention, further testing and possibly specialist
referral)
2. Symptoms:
Constant, progressive, nonmechanical pain at night or at rest / pain at multiple sites
General malaise / rapid fatigue
Reduced appetite
Fever ≥38 °C
Unexplained weight loss >10 kg within 6 months
Saddle anesthesia / perineal numbess
Sudden onset of bladder dysfunction / fecal incontinence
Thoracic (or abdominal pain)

3. Signs

Increased thoracic kyphosis

Structural defomity
Reduced anal sphincter tone
Pain increase in flexion Commented [nlk1]: Why?
Spread sensory deficit (in lower limbs)
Gait disturbance / abnormality Commented [nlk2]: Why?
Progressive weakness in lower limbs/lower motor neuron weakness (strength 3 of 5 or
less)
Significant limitation of lumbar flexion Commented [nlk3]: Why?
Not flexion of 5th lumbar spine Commented [nlk4]: How to tell from P/E?
Foot drop
Abdominal pulsating mass

4. Age >50 years old, pain at multiple sites, history of renal malignancy, weakness with right
knee extension
In lumbar canal stenosis, pain should be relieved by forward lumbar flexion as the narrowed spinal
canal foraminal spaces are opened up, however if aggravated, it most likely reflects mechanical
cause (disc disorders) or discogenic LBP.

Gait disturbance indicates severe and/or progressive neurological deficit in lower extremities eg in
lumbar herniated disc causing weakness and pain which can produce subtle gait changes. Severe
degree of spinal stenosis can also produce wide-based gait

Found limitation of lumbar flexion as a red flag documented in quite number of sources, guess it’s a
general red flag for nonspecific back pain with low specificity. Guess can measure during active
lumbar flexion or during Schober’s test