What are the alarming symptoms of back pain that require immediate medical attention?

Alarming Symptoms of Back Pain Requiring Immediate Medical Attention

Back pain with any of the following alarming symptoms requires immediate medical attention as they may indicate serious underlying conditions that could lead to significant morbidity or mortality if not promptly addressed.

Signs of Cauda Equina Syndrome

• Urinary retention (90% sensitivity for cauda equina syndrome) 1
• Fecal incontinence 1, 2
• Saddle anesthesia (numbness in the genital/rectal region) 1, 2
• Motor deficits at multiple levels 1, 2
• Bladder dysfunction 1

Indicators of Possible Spinal Malignancy

• History of cancer (positive likelihood ratio 14.7) 1, 2
• Unexplained weight loss (positive likelihood ratio 2.7) 1, 2
• Failure to improve after 1 month (positive likelihood ratio 3.0) 1, 2
• Age older than 50 years (positive likelihood ratio 2.7) 1, 2
• New and/or increasing severe back or neck pain 1
• Pain between or just below the shoulder blades 1
• Back pain when lying down (during sleep) that disappears when sitting up 1
• Radiating pain in the stomach, chest, arms or legs 1

Signs of Spinal Infection

• Fever 1, 2
• Recent infection 1, 2
• Intravenous drug use 1, 2
• Immunocompromised status 1, 2

Indicators of Spinal Instability or Neurological Compromise

• Decreased strength in the legs (and sometimes the arms) 1
• Difficulty controlling the legs (and sometimes the arms) 1
• A very wobbly gait 1
• Numbness or tingling radiating down from chest, stomach, groin, and/or legs 1
• Inability to walk and/or stand, or legs giving way 1
• Positive crossed straight-leg-raise test (specificity 88%) 1

Timing of Medical Attention

• Symptoms of cauda equina syndrome require emergency evaluation 1, 2
• Suspected spinal malignancy with neurological symptoms requires urgent MRI within 12 hours 1
• Suspected spinal malignancy without neurological symptoms requires MRI within 2 weeks 1

Important Clinical Considerations

• The posttest probability of cancer increases from approximately 0.7% to 9% in patients with a history of cancer presenting with back pain 1, 2
• Cauda equina syndrome is rare (prevalence 0.04% among patients with low back pain) but requires immediate intervention to prevent permanent disability 2
• Spinal infections account for only about 0.01% of back pain cases but have high morbidity and mortality if not promptly treated 2

Common Pitfalls to Avoid

• Delaying imaging in patients with suspected red flag conditions 2, 3
• Failing to recognize that conventional x-rays, CT scans, or bone scintigraphy cannot reliably exclude spinal metastases; MRI is the imaging modality of choice 1
• Missing early signs of ankylosing spondylitis, which may include morning stiffness, improvement with exercise, alternating buttock pain, and awakening due to back pain during the second part of the night 1