Back pain assessment

A middle aged patient presents with increasing back pain.  It had started fairly recently and they had been sent for an X-Ray a few days before.  Now it is worsening.

The report states that they have a wedge fracture, and asks if there has been a history of trauma. A medical student asked whether the patient had any red flags?  Can you name them all?  The Physio then mentioned Yellow flags.  I looked blank at this point.

The red flags for acute back pain, suggesting that you need to investigate further, are:

a. Neurological: 
• Sphincter and gait disturbance
• Saddle anaesthesia
• Severe or progressive motor loss
• Widespread neurological deficit

b. Other:
• Age <20 or >55 years
• Previous malignancy
• Systemic illness
• HIV
• Weight loss
• IV drug use
• Steroid use
• Structural deformity
• Non-mechanical pain (no relief with bed rest)
• Fever
• Thoracic pain

Don't forget that there is quite a wide differential (including spinal stenosis, lower limb oedema, nerve root compression, peripheral neuropathy, cervical myelopathy, alcoholism, diabeties, MS and UMND) so start with imaging and basic bloods: U&Es, FBC, inflammatory markers, Calcium and think about a Myeloma screen.
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Here's a good work through an acute back pain scenario which covers the main points.

None of the red flags are particularly strongly predictive by themselves.  For fracture, the most predictive are visible local trauma (contusion/abrasion) and steroid use.  For malignancy, it's past history of malignancy (33% pretest probability).

After the red flags come the Yellow flags - risk factors for long term disability.  With the great mnemonic ABCDEFW! Now you know!

Simon.