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Red Flags - Back Pain

Indications for urgent referral include; 

  • painful scoliosis
  • night waking
  • neurological symptoms suggestive of nerve root entrapment or cord compression eg cough impulse, pins and needles, nerve root pain or sphincter disturbance (bladder / bowel)
  • systemic findings to suggest malignancy or sepsis
  • very young children (<5 years)
  • suggestion of inflammatory back pain (morning stiffness / pain)

The differential must include infection (abscess, osteomyelitis), malignancy or an orthopaedic urgency (such as prolapsed disc or spondylolisthesis). These may be suggested by red flags in the clinical assessment. Clinical concern warrants urgent referral and do not wait for investigations. Refer to orthopaedics or paediatric rheumatology. 

The MRI below shows a spinal cord tumour presenting with back pain, night waking and root symptoms

The radiograph below shows vertebral abscess and scoliosis due to Tuberculosis (Pott's disease)

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