Low Back Pain Warning Signs

DDx is broad, but includes mechanical/trauma vs. inflammatory arthritis vs. malignancy vs. infection vs. visceral/referred pain (ie. AAA, pancreatitis, nephrolithiasis)      

Low back pain is extremely common and usually have a benign musculoskeletal etiology.  However, numerous "red flags" exist and should warrant further workup such as imaging:

• Fevers
• Weight Loss
• History of cancer or unintentional weight loss
• Immunosuppression
• IV drug abuse
• Focal neurological dysfunction, including bowel/bladder incontinence or saddle anesthesia
• Increased pain at night or when lying down (suggests a space-occupying lesion)
• Age > 70
• Persistent duration > 6 weeks
• significant trauma or age >50 with minor trauma
• osteoporosis, h/o glucocorticoid use

These red flags should increase suspicion for infectious etiologies (epidural abscess, osteomyelitis), malignancy (usually bone mets), and other potentially catastrophic syndromes (cord compression, cauda equina)

Imaging, when indicated can include plain films (only shows bony abnl, may be normal in early infection), CT or MRI (most sensitive)

Urgent neurosurgical referral if presence of cauda equina syndrome/SC compression, or persistent radiculopathy (numbness, weakness, radiating pain etc.)

(Victoria Kelly MD, 8/5/10)

(Chanu Rhee MD, 9/30/10)