Community Red Flags for Lower Back Pain / Radicular Pain

Emergency Spinal Referral (Immediate or Same Day to local spinal surgical service)

• Suspected deteriorating spinal cord pathology (gait disturbance, multilevel weakness in the
legs and / or arms)
• Suspected Cauda Equina Syndrome (link)
• Suspected spinal infection

Priority Spine Referral (to be seen within 2 weeks of referral by MSK triage or spinal service)

• Major motor loss (power <3/5 MRC grade)

• Past history of cancer (new onset spinal pain)
• Recent unexplained weight loss
• Objectively unwell with spinal pain (thoracic, band-like or persisting non-mechanical)
• Raised inflammatory markers (plasma viscosity, CRP, ESR)
• Possible immunosuppression with new spinal pain (IVDU, HIV, chemotherapy, steroids)
• Prolonged steroid use
• Known osteoporosis, with new severe spinal pain
• Age <15, or >60 years with first ever episode of axial back pain

Key Clinical Messages

• Few red flags, when used in isolation, are informative. Combinations of red flags
demonstrate promise, but this work requires further validation.
• Red Flags remain the best tools at the clinician’s disposal to raise suspicion of serious spinal
pathology, when used within the context of a thorough subjective patient history and physical
examination.
• Clinicians should consider both the evidence to support red flags and the individual profile of
the person’s determinants of health (e.g. age, sex) to decide the level of concern (index of
suspicion) for presence of serious spinal pathology.

Red Flags are features of an individual’s medical history and clinical examination thought to be
associated with a high risk of serious disorders such as infection, inflammation, cancer or fracture.
Red flags are clinical prediction guides – they are not diagnostic tests, and they are not necessarily
predictors of diagnosis or prognosis. The main role of red flags in that, when combined, they help to
raise the clinician’s index of suspicion. Unfortunately, with a few exceptions, the prognostic strength
of individual red flags or combinations of red flags is not known.

Safety netting is a management strategy used for people who may present with possible serious
pathology. These strategies should include advice on which signs and symptoms to look out for,
which action to take, and the time frame within which that action needs to be taken.