Low back pain is very common and affects as many as four out of five people. It can also really get in the way of everyday life. It can slow you down, prevent you from playing with your kids or grandkids, and it can make work agony. But sometimes low back pain can be even more than that. Sometimes it can be downright scary. Because sometimes, we don’t know what is causing it. Could it be cancer? A rare disease? A permanent injury that you will have to live with forever? The good news is that most cases of back pain are not serious, but do you know when it’s serious and when it isn’t?
What Are Red Flags?
Have you ever heard about red flags? Not the type you find at the beach that tell you when it isn’t safe to swim. The red flags we are going to talk about today are warning signs that something in your body may not be what it seems. This can happen with low back pain. Fortunately, statistics tell us that low back pain is often not serious and will resolve by itself, within a few weeks. Red flags refer to symptoms that might accompany your low back pain and can help give you an indication of when you might want to seek professional advice.
In the US, there has been an increasing trend for patients with low back pain to seek care at urgent care and ambulatory care centers. The CDC reported that “back-related complaints accounted for more than 5.7 million visits to urgent and ambulatory care clinics in 2016”. When you are in excruciating pain it can be difficult to know if there is something more serious going on, or if your pain is going to go away on its own. Understandably, people are looking for reassurance regarding their condition.
While the presence of red flags is not always cause for alarm, if you have low back pain along with any of the red flags that we are going to talk about in this article, it is probably a good idea to make an appointment with your healthcare provider and talk about your symptoms. Your doctor will be able to look into your concerns and possibly order some diagnostic tests to see if there is anything more serious going on. Better to be safe than sorry.
Although low back pain becomes more common the older we get, age can actually be a red flag for low back pain. If you are younger than 18 or older than 50, you should consider your age as a low back pain red flag. If you are younger than 18 doctors sometimes worry about the presence of congenital defects, vertebral fractures or spondylosis. If you also have night pain and weight loss, along with your back pain, your doctor will definitely want to rule out the possibility of any serious pathologic conditions.
If you are over 50 and you have brand new back pain (you don’t typically suffer from low back pain), your doctor will probably want to make sure that there isn’t anything else that could be causing it. Conditions such as tumors, infections, abdominal aortic aneurysms and pancreatitis should be ruled out. Vertebral fractures are also potential causes of new onset low back pain after age 50.
Blood thinners (anticoagulants) like Heparin and Warfarin are medications that people take to reduce blood clotting. Patients who have had bypass surgery or other heart conditions often take blood thinners. These medications can be a red flag for new low back pain as they can potentially cause spontaneous epidural hematomas, although it is very rare.
Fever is a big red flag for almost everything. In general, when you have a fever it is a sign of infection. This often means that there is something else going on with the body that may, or may not, be related to low back pain. The presence of a fever could indicate a potential spine infection (osteomyelitis), which is pretty rare but has an incidence of 6.5 cases per 100,000 and has been reported to be increasing. A fever can also indicate a kidney infection, a UTI, or other types of bladder infections that could potentially cause low back pain. This is why fever should always be taken seriously as a red flag in patients with back pain.
Major trauma is another red flag for low back pain. When you experience a major trauma to your back it can cause spinal cord compression from vertebral fractures. Elderly patients with even minor trauma should also be evaluated as even a smaller fall from a chair or a bed could cause a fracture, especially if they have Osteoporosis. Your doctor will probably want to order an x-ray to check for a fracture if you have recently had any sort of trauma or fall.
Cauda equina syndrome (CES) is a condition that occurs when the nerves below the end of the spinal column are damaged. If you have any sort of neurological issues such as numbness, loss of bowel or bladder control, or pain that radiates down your leg, you should definitely see your healthcare provider. Cauda equina syndrome can be diagnosed through imaging like an MRI or a CT scan and is generally treated surgically. It is important to have this diagnosed and treated as quickly as possible as it can make a big difference in successful treatment and recovery.
History of Cancer
If you have a history of cancer it is important to get any low back pain checked out by a medical professional. Research suggests that the spine is prone to receiving cancer cells that have spread from other parts of the body. Patients who have a history of breast, lung, thyroid, kidney, prostate, lymphoma or sarcoma are at high risk for metastatic disease to the spine. More than 90% of patients with this disease report back pain as their initial symptom. This is a very serious red flag and you should speak with your healthcare provider immediately.
When it comes to pain, intensity is actually quite a poor indicator of seriousness. Some of the worst cases of back pain are actually the least painful, especially early on. Cauda Equina syndrome, for example, can be very serious but yet, doesn’t cause a lot of pain. Some patients have no pain at all! Muscle cramps, on the other hand, can be excruciatingly painful, but are not very serious.
When it comes to pain and red flags, however, what is important is the type of pain. Sharp pain, rather than a dull ache, could indicate a torn muscle or ligament, or it could indicate a more serious problem with an internal organ. Likewise, a radiating pain that “shoots”, or moves, toward your legs or glutes could be a sign of a nerve compression condition. If you experience either of these types of pain you should definitely speak with your healthcare provider.
IV Drug Use
Patients with current (or even long past history of) IV drug use are at high risk for a condition called bacteremia. This can cause spondylodiscitis and epidural abscesses. A review by Galliker and colleagues found that IV drug use was a red flag that was one of the most accurate indicators for epidural abscesses.
Because low back pain is such a common occurrence, it can be helpful to know what red flags to look out for if you are wondering if your back pain is more serious. Generally speaking, red flags are helpful to both low back pain sufferers ,and their healthcare providers, to help identify the cause of low back pain. Knowing what red flags to look out for can help to reduce the number of missed or incorrect diagnoses, reduce the number of ER visits and can help make sure that serious diagnosis can be made faster, with better outcomes.
It is important to know, however, that, while a positive response to a red flag question may indicate the presence of serious disease, research has shown that a negative response to 1 or 2 red flag questions does not meaningfully decrease the likelihood of a red flag diagnosis. Doctors should be very careful when they use red flag questions as screening tools.