Excluding a serious underlying pathology in people with back and neck pain

Henschke, 2013 Williams, 2013

It is important when assessing a person presenting with back or neck pain to exclude serious underlying medical and spinal pathologies. The presence of these conditions is often indicated by alerting features (also known as ‘red flags’). If an alerting feature is present, it is important to investigate the person to rule out any serious pathology.

For further advice on the alerting features (‘red flags’) of serious pathology in people with back or neck pain, see Serious pathologies requiring urgent management in patients with back and neck pain and their alerting features (‘red flags’).

Table 1. Serious pathologies requiring urgent management in patients with back and neck pain and their alerting features (‘red flags’)
[NB1]
Serious pathology	Alerting features [NB2]
spinal infection (eg osteomyelitis, epidural abscess)	symptoms and signs of infection (eg fever) risk factors for infection (eg underlying disease, immunosuppression, penetrating wound, history of injecting drugs) recent injury, dental or spinal procedure raised inflammatory markers (eg serum CRP concentration, ESR) [NB3]
vertebral fracture	history of a recent significant trauma (for whiplash-associated disorder see The Canadian C-Spine Rule for advice on imaging and excluding a fracture) history of minor trauma if age older than 50 years history of osteoporosis or taking corticosteroids presence of bruising or abrasion
malignancy	history of malignancy age older than 50 years failure to improve with adequate analgesic treatment unexplained weight loss pain at multiple sites pain at rest pain at night symptoms in other body systems (eg cough, dysphagia)
visceral disease (eg pancreatitis, aortic aneurysm [leak or rupture])	sudden, unexplained onset of pain absence of aggravating features (eg pain not aggravated by spinal movement) associated collapse or hypotension abdominal pain radiating to the back
cauda equina compression	altered bladder and/or bowel function (eg urinary retention, faecal incontinence) reduced sensation or numbness in the ‘saddle’ area persistent or progressive bilateral foot or leg weakness
spinal cord pathology (myelopathy, see also cervical myelopathy)	a sensory level weakness hyperreflexia or hyporeflexia upgoing plantar responses sensory loss disturbance of gait or balance
axial spondyloarthritis	younger age (onset before 40 years) symptom duration of longer than 3 months prolonged morning stiffness and night pain alternating buttock pain improvement of symptoms with physical activity or exercise, and failure to improve with rest response to NSAIDs peripheral symptoms (eg alternating buttock pain, arthritis, enthesitis, dactylitis) extra-articular symptoms (eg psoriasis, IBD, uveitis)
Note: CRP = C-reactive protein; ESR = erythrocyte sedimentation rate; IBD = inflammatory bowel disease; NSAIDs = nonsteroidal anti-inflammatory drugs NB1: This list is not exhaustive. NB2: The presence of a single alerting feature is associated with a small increased likelihood of serious pathology compared with the presence of multiple alerting features. NB3: ESR and serum CRP concentration should only be measured if other alerting features for spinal infection are present.