Alarming Symptoms of Back Pain Requiring Immediate Medical Attention

Signs of Cauda Equina Syndrome

Urinary retention has a 90% sensitivity for cauda equina syndrome, according to the American College of Physicians, in patients with low back pain 1
Fecal incontinence is a symptom of cauda equina syndrome, as reported by the American College of Physicians 1
Saddle anesthesia, or numbness in the genital/rectal region, is a symptom of cauda equina syndrome, as reported by the American College of Physicians 1
Motor deficits at multiple levels are a symptom of cauda equina syndrome, as reported by the American College of Physicians 1
Bladder dysfunction is a symptom of cauda equina syndrome, as reported by the American College of Physicians 1

A history of cancer has a positive likelihood ratio of 14.7 for spinal malignancy, according to the American College of Physicians, in patients with low back pain 1
Unexplained weight loss has a positive likelihood ratio of 2.7 for spinal malignancy, according to the American College of Physicians, in patients with low back pain 1
Failure to improve after 1 month has a positive likelihood ratio of 3.0 for spinal malignancy, according to the American College of Physicians, in patients with low back pain 1
Age older than 50 years has a positive likelihood ratio of 2.7 for spinal malignancy, according to the American College of Physicians, in patients with low back pain 1
New and/or increasing severe back or neck pain is a symptom of possible spinal malignancy, as reported by the National Comprehensive Cancer Network 3
Pain between or just below the shoulder blades is a symptom of possible spinal malignancy, as reported by the National Comprehensive Cancer Network 3
Back pain when lying down that disappears when sitting up is a symptom of possible spinal malignancy, as reported by the National Comprehensive Cancer Network 3
Radiating pain in the stomach, chest, arms, or legs is a symptom of possible spinal malignancy, as reported by the National Comprehensive Cancer Network 3

Fever is a symptom of spinal infection, as reported by the Infectious Diseases Society of America 1
Recent infection is a risk factor for spinal infection, as reported by the Infectious Diseases Society of America 1
Intravenous drug use is a risk factor for spinal infection, as reported by the Infectious Diseases Society of America 1
Immunocompromised status is a risk factor for spinal infection, as reported by the Infectious Diseases Society of America 1

Decreased strength in the legs and sometimes the arms is a symptom of spinal instability or neurological compromise, as reported by the American Academy of Neurology 3
Difficulty controlling the legs and sometimes the arms is a symptom of spinal instability or neurological compromise, as reported by the American Academy of Neurology 3
A very wobbly gait is a symptom of spinal instability or neurological compromise, as reported by the American Academy of Neurology 3
Numbness or tingling radiating down from the chest, stomach, groin, and/or legs is a symptom of spinal instability or neurological compromise, as reported by the American Academy of Neurology 3
Inability to walk and/or stand, or legs giving way, is a symptom of spinal instability or neurological compromise, as reported by the American Academy of Neurology 3
A positive crossed straight-leg-raise test has a specificity of 88% for spinal instability or neurological compromise, as reported by the American College of Physicians 1

Symptoms of cauda equina syndrome require emergency evaluation, as recommended by the American College of Emergency Physicians 1
Suspected spinal malignancy with neurological symptoms requires urgent MRI within 12 hours, as recommended by the National Comprehensive Cancer Network 4
Suspected spinal malignancy without neurological symptoms requires MRI within 2 weeks, as recommended by the National Comprehensive Cancer Network 4

The posttest probability of cancer increases from approximately 0.7% to 9% in patients with a history of cancer presenting with back pain, as reported by the American College of Physicians 1
Cauda equina syndrome is rare, with a prevalence of 0.04% among patients with low back pain, but requires immediate intervention to prevent permanent disability, as reported by the American College of Physicians 1
Spinal infections account for only about 0.01% of back pain cases but have high morbidity and mortality if not promptly treated, as reported by the Infectious Diseases Society of America 1

Delaying imaging in patients with suspected red flag conditions is a common pitfall, as reported by the American College of Radiology 2
Failing to recognize that conventional x-rays, CT scans, or bone scintigraphy cannot reliably exclude spinal metastases, and that MRI is the imaging modality of choice, is a common pitfall, as reported by the National Comprehensive Cancer Network 4
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, is a common pitfall, as reported by the American College of Rheumatology 1