Low Back Pain Red Flag


Low Back Pain Red Flag, Serious Low Back Symptoms, Low Back Pain suggestive of Spinal Fracture, Low Back Pain Suggestive of Cancer, Low Back Pain Suggestive of Infection, Low Back Pain Suggestive of Neurologic Injury, Low Back Pain Suggestive of Aortic Aneurysm

  • Precautions
  1. Low back red flag check lists have poor Test Specificity
    1. Many patients with Low Back Pain have at least one red flag (>80%)
  2. Evaluate red flags in the context of the clinical presentation as a whole
    1. Keep a high index of suspicion in high risk patients or where more than one red flag is present
    2. Positive red flags are typically indications for imaging
  • Red Flags
  • Summary (Mnemonic: TUNA FISH, as an aid to documentation)
  1. T - Trauma
  2. U - Unexplained Weight Loss
  3. N - Neurologic findings (includes bowel or bladder Incontinence and other Cauda Equina Syndrome symptoms)
  4. A - Age >55 years (or age >65 years)
  5. F - Fever
  6. I - Immunocompromised
  7. S - Steroids
  8. H - History of HIV, Tuberculosis, Cancer
  9. References
    1. Mallon (2019) CCME EM Board Review, Las Vegas, accessed 8/1/2019
  1. See Spinal Neoplasm
  2. History of cancer (esp. recent)
    1. Breast Cancer
    2. Lung Cancer
    3. Prostate Cancer
    4. Renal Cancer
    5. Gastrointestinal Cancer
    6. Thyroid Cancer
    7. Multiple Myeloma
    8. Non-Hodgkin's Lymphoma
  3. Unexplained Weight Loss >10 kg within 6 months
  4. Age over 50 years or under 18 years old
  5. Failure to improve with therapy
  6. Pain persists for more than 4 to 6 weeks
  7. Night pain or pain at rest
  1. See Cauda Equina Syndrome
  2. Urinary Incontinence or retention
  3. Saddle Anesthesia
  4. Anal sphincter tone decreased or Fecal Incontinence
  5. Bilateral lower extremity weakness or numbness
  6. Progressive neurologic deficit
    1. Major motor weakness
    2. Major sensory deficit
  • Red Flags
  • Significant Herniated nucleus pulposus
  1. Major Muscle Weakness (strength 3 of 5 or less)
  2. Foot Drop
  1. See Thoracolumbar Trauma
  2. See Vertebral Compression Fracture
  3. Prolonged use of Corticosteroids
  4. Age greater than 70 years
  5. History of Osteoporosis
  6. Mild Trauma over age 50 years (or with Osteoporosis)
  7. Recent significant Trauma at any age
    1. Ejection from motor vehicle
    2. Fall from substantial height
  1. Risk Factors (males over age 65 years with a history of Tobacco Abuse)
  2. Abdominal pulsating mass
  3. Atherosclerotic vascular disease
  4. Pain at rest or nocturnal pain
  5. Renal Colic presentation without a history of known aneurysm
  1. Vertebral tenderness
  2. Limited spine range of motion