Red Flags - Back and Neck Pain

Indications for urgent referral include:

• painful scoliosis.
• night waking.
• neurological symptoms suggestive of nerve root entrapment or cord compression e.g., 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).
• acquired torticollis.
• Additional Red flag features of neck pain are:
• Symptoms of high intracranial pressure (headaches and vomiting).
• Focal/abnormal neurological examination.

The differential must include infection (abscess, osteomyelitis), malignancy or an orthopaedic emergency (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 depending on the clinical presentation.

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