Back pain red flags: when to worry and when not to
Almost everyone with a bad back wonders, at some point, whether it's something serious. Usually it isn't. But a small number of back pain cases do have a serious cause, and knowing the warning signs helps you act quickly when it matters and worry less when it doesn't.
How often is back pain serious?
Rarely. In a study of 1,172 people seeing a primary care clinician for a new episode of low back pain, 0.9% had a serious underlying condition, and most of those were spinal fractures (Henschke et al., Arthritis & Rheumatism, 2009). More than 99 in 100 had ordinary back pain.
What are red flags?
Red flags are features in your history or symptoms that raise the possibility of a serious cause, such as a fracture, cancer, infection or severe nerve compression. They prompt further questions, examination and sometimes tests. A red flag isn't a diagnosis; most people with one still turn out to have ordinary back pain.
Which back pain symptoms need emergency care?
Go to an emergency department straight away for back pain with new difficulty passing urine or controlling your bladder or bowels, numbness around the genitals, anus or inner thighs, or weakness or numbness in both legs. These can be signs of cauda equina syndrome, where the nerves at the base of the spine are compressed, and it needs urgent treatment. Also call 000 for sudden, severe, tearing pain in the back or abdomen, particularly with dizziness or fainting, or back pain with chest pain or breathlessness.
What are the red flags for a spinal fracture?
A systematic review found the most informative signs were older age, prolonged use of corticosteroid medication, significant trauma, and a bruise or graze over the area, and that the chance of a fracture rose sharply when several were present together (Downie et al., BMJ, 2013). Osteoporosis is the main underlying reason: in someone with fragile bones, a minor fall, a lift or even a cough can cause a compression fracture.
What are the red flags for cancer?
A previous history of cancer is the most important. Others that guidelines list include unexplained weight loss, pain that's constant and not eased by rest or changing position, and feeling generally unwell. The same review found that a history of cancer was the most informative of these; the others are worth mentioning to your doctor but are less specific.
What are the red flags for infection?
Back pain with fever, chills or feeling unwell, especially after a recent infection or surgery, in people with a weakened immune system, or in people who inject drugs. Spinal infections are uncommon but need prompt treatment.
What about leg weakness and numbness?
Leg pain, pins and needles or numbness in one leg is common with sciatica and usually settles. See your GP promptly if you have weakness that's getting worse, such as a foot that slaps or catches when you walk, or difficulty rising onto your toes or heels.
Is night pain a red flag?
Pain that's worse when you lie in certain positions or roll over is common with ordinary back pain. Pain that's constant, unrelated to position and stops you getting back to sleep whatever you do is the pattern that deserves a GP visit.
See our post on back pain at night.
Could it be inflammatory arthritis?
In people under 45, back pain that came on gradually, is worst in the second half of the night and early morning, with stiffness lasting more than 30 minutes, and improves with exercise but not rest, may be inflammatory. It's worth discussing with your GP.
Are red flag lists reliable?
They're imperfect. A review of 16 guidelines found 46 different red flags listed, with little agreement between guidelines and limited evidence for their accuracy (Verhagen et al., European Spine Journal, 2016). In the primary care study above, 80% of patients had at least one red flag, yet fewer than 1% had a serious condition. That's why clinicians look at the whole picture rather than ticking boxes.
What's reassuring?
Pain that changes with movement and position, pain that began after a lift, twist or new activity, feeling otherwise well, no fever or weight loss, normal bladder and bowel function, and symptoms that are gradually improving.
Do I need a scan to be sure?
Not usually. Without red flags, scans rarely change management and often show age-related changes that aren't the cause. With red flags, your doctor will arrange the appropriate tests.
Can other organs cause back pain?
Yes. Kidney stones and infections, gynaecological conditions, pancreatitis and problems with the aorta can all be felt in the back. Pain that doesn't change with movement, or comes with fever, urinary symptoms, abdominal pain or nausea, needs a doctor.
How does an osteopath screen for red flags?
Every first appointment includes questions about your general health, medical history, medications and the pattern of your pain, plus a neurological examination where needed. If anything suggests a serious cause, we refer you to your GP or an emergency department before any treatment.
See our posts on whether to see an osteopath or GP first and our back pain treatment in Berwick page. Book an assessment at our Berwick clinic. A 60-minute initial consultation is $149, with no referral needed and HICAPS on-site.
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Book an initial consultation at RISE Sports & Spinal in Berwick. Clear diagnosis, hands-on treatment, and a plan that actually gets you better.
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