Red flags for spinal conditions

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:

NB: 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.

Urgent spinal 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:

GP / Primary Clinician

Consider diagnosis (discuss within peer review)

  • Screen for red flags serious causes.

Examine for:

  • Associated deformity e.g. step or kyphosis or scoliosis.
  • Associated neurological deficit.
  • May present with radiculopathy (follow radiculopathy pathway)
  • Cross refer with ageing spine pathway.


  • Spondylolysis - the dorsum of the vertebra fails to fuse with the centrum. Occurs in 3-6% of patients and is a defect in the pars interarticularis. This most commonly affects lower lumbar vertebrae, eg L4 or L5.
  • Spondylolysis commonly results in Spondylolisthesis acquired in up to 12 % population; sustained repeated spinal stress perhaps underlying pars defect (gymnastics, weightlifters, cricketers).
  • Note underlying spina bifida-failure of dorsal arches to fuse may be an incidental finding and does not indicate requirement for referral.
  • Pars defect may progress to spondylolisthesis with degenerate disc disease.
  • Maybe iatrogenically acquired: e.g. Post-surgically.

Clinical presentation:

  • Back pain may radiate to thighs/ buttocks.
  • Often worse with activity maybe particularly extension / weight bearing.
  • Occasional “step” palpated on back.
  • Maybe tender spinal processes.
  • Consider stable or unstable?

Undertake bio-psychosocial assessment and management.


In the absence of radiculopathy initial management (follow acute back pain pathway).

Spondylolisthesis Grades II ( 50% and above) with intrusive pain and disability consider referral via interface team.

Initial management consider self-refer or referral to Physiotherapy.

Where unresolved a severe persistentpainfulsymptoms consider referral to Interface Team.


  • Routine x-rays not indicated (as initially managed as acute back pain).
  • Consider standing lumbar X-ray views if suspicious of bony pathology e.g. fracture, tumour or infection or if considering referral for intervention.


  • Consider guidelines in previous section.
  • Assessment / Diagnosis/ Detailed advice and information.
  • Individualised care according to type – stable or unstable- to stabilise or mobilise
  • Combinations of appropriate multi-modal package of care with an emphasis on pain self-management.
  • Individual exercise combinations of aerobic activity, spinal mobility and strength.
  • Consideration of Manual therapy as part of package of care and functional restoration.

If not responding consider guidelines above and appropriate referral to Interface Team.

Interface Team
  • Review previous assessment, diagnosis and management.
  • If not responding consider investigation (if diagnosis unclear).
  • Particular review of comprehensiveness and appropriateness of conservative management.
  • Risk factors for poor prognosis – following surgery – should be identified and management optimal prior to any surgical referral.
  • Consideration of bracing.
  • Consider Refer back to GP for advice re. optimal analgesia.
  • If presence of psychosocial barriers to self –care (i.e. 5 D’s:- distress, disability, diagnostic uncertainty, drug escalation and dependency) – consider referral to Pain Clinic.
  • If patient not suited or not seeking surgery consider Pain Clinic referral

Consider referral to Surgeon if fits criteria.


  • Lumbar Spine standing X-rays if no improvement and considering referral for intervention.
  • MRI scan may be indicated as a second line investigation when no improvement and considering referral for intervention
  • In suspected post-surgical instability lumbar spine standing extension and flexion views maybe considered by specialist team.
Surgical Criteria

No referrals to secondary care unless:

  • Patient experiences intrusive pain despite 12 months of comprehensive conservative management


  • Patient has demonstrated motivation and adhered to rehabilitation and advice


  • The patient has shown commitment to weight reduction through active participation in a weight management programme if the patient's BMI is >30


  • Review by Interface suggests patient likely to benefit from further management/surgery by an orthopaedic consultant or referral to a secondary care pain clinic.


  • Where surgical intervention is appropriate a Health Care Professional has discussed surgery with the patient who has confirmed they want explore surgery


  • General Health including fitness for anaesthesia has been considered and believed adequate to proceed to potential surgical intervention and it is believed that the patient is likely to derive quality of life benefits from surgery


Individual Funding Requests

Certain spinal procedures are listed on Gloucestershire CCG's Effective Clinical Commissioning Policy.  Please the attached link for details of access criteria and funding arrangements.

  • Various surgical procedures or combinations of nerve root surgical decompression and or laminectomy and fusion / stabilisation.
  • Stabilisation / fusion for back pain alone, is generally only considered after comprehensive conservative measures.