Red Flags
Serious pathology in the absence of an obvious cause (eg trauma) is very rare, but be aware of signs suggestive of more serious pathology.
Symptoms suggestive of cauda equina syndrome (compression of the cauda equina):
  • loss of bowel control (faecal or flatus incontinence) and unexpected laxity of anal sphincter
  • loss of bladder control (urinary retention or incontinence)
  • severe or progressive neurological deficit in the lower extremities or gait disturbance
  • saddle anaesthesia or paraesthesia (loss or change of perianal and perineal sensation)


Significant symptoms that may suggest cancer:
  • new onset pain in patient over age 50 years (defined as over age 55 years in some guidelines), or younger than age 20 years
  • incidence of pain in adolescents is becoming increasingly common; epidemiological surveys show point prevalence rates of around 30%
  • history of cancer
  • failure to improve after one month


Other symptoms that may suggest cancer include:
  • persistent night pain (unrelieved by change in position)
  • structural deformity of the spine
  • pain at multiple sites
  • unexplained weight loss


Symptoms that may suggest infection:
  • fevers, chills, rigors
  • immunosuppression
  • intravenous (IV) drug misuse
  • recent bacterial infection
  • penetrating wound


Symptoms that suggest fracture:
  • sudden onset of back pain associated with major trauma or minor trauma in people with osteoporosis or in those taking corticosteroids
  • structural deformity of the spine
  • severe central pain, relieved by lying down


Red flags may also be indicated by:
  • sensory or motor loss
  • history of serious injury
  • in people with or at high risk of osteoporosis
  • other disorders which increase the chance of serious aetiology, eg:

Practice Point

Be aware that some red flags have very high false-positive rates and as such have little diagnostic value in primary caresettings. Careful clinical judgment to decide whether to investigate further or refer is needed.

Practice Point

Please see the Urgent Care: general section to SWAST's guidance on Requesting Ambulance Transport (999 or Urgent).

Urgent Referral

Patients with any of the following suspected should be sent to A&E:

  • Suspected Cauda Equina Syndrome (not of metastatic origin).
  • Violent trauma
  • Rapid onset of new neurology (upper or lower motor neurone signs).
  • Back pain with fever or raised inflammatory markers (discitis / osteomyelitis)
  • Minor head / neck / spine trauma in known Ankylosing Spondylitis / at risk osteopenic
  • Confirmed metastatic spinal cord compression (MSCC) on imaging (consider direct referral to Oncology).

Consider urgent referral to Consultant Spinal Surgeon Clinic (where certain of malignancy contact Oncology):

  • Back pain in presence of cancer with objective signs of new recent onset neurological deficit (suspicious of tumour or metastasis).
  • Back pain with confirmed presence of spinal cancer on MR imaging.
  • Back pain with constitutional features (loss of weight, fever etc)
  • Constant unrelenting back or neck pain / especially unrelenting night pain
  • Thoracic back pain – suggestive of fracture, tumour, infection
  • Back or neck pain in less than 18 years old
  • Back or neck pain in intravenous drug users; steroid use; HIV; immunocompromised.
  • Progressive or significant neurological loss or more than one nerve root affected (upper or lower limbs), insidious onset.
  • New, worsening or significant structural deformity: Kyphosis, Scoliosis, (including osteoporotic collapse)
  • New onset or progressive myelopathic symptoms and signs
  • Recent surgery 3/12

Urgent referral to Rheumatology Clinics for suspected spondyloarthropathy: