- Thoracic pain.
- Age of onset less than 20 or more than 55 years.
- Loss of control of the bowel or bladder.
- Weakness or numbness in a leg or arm.
- Foot drop, disturbed gait.
- High fever.
- Saddle anaesthesia (numbness of the anus, perineum or genitals).
- History of carcinoma.
- Structural deformity.
These symptoms could indicate spinal cord compression, possible cauda equina syndrome or the presence of a tumour or infection. It is important to try to establish the type of pain as well as where and when it is felt.
As well as these symptoms, you should also be aware of: trauma - whether the patient had a recent fall from a height or a traffic accident; unexplained weight loss; any steroid use; difficulty passing urine; ill health or any other medical conditions.
Gradual onset before the age of 40 could indicate an inflammatory disorder. It is essential to find out the patient's history of cancer because the primary site or any metastases could cause back pain.
- Lumbar disc herniation.
- Peripheral neuropathies.
- Cauda equina syndrome.
- Primary or metastatic carcinoma.
- Mechanical origin.
- Disease of rheumatoid, vascular or visceral origin.
- For advice on referring patients with acute low back pain see the NICE Referral Advice document published in 2001: www.nice.org.uk/nicemedia/pdfReferraladvice.pdf.