Consider red flags

Generic red flag signs

  • First acute onset age <20 or >55
  • Non-mechanical pain
  • PMH: carcinoma (esp. breast, lung, prostate, kidney, thyroid), steroids, HIV
  • Unwell, weight loss
  • Widespread neurology – unilateral or bilateral limb weakness and/or numbness extending over several dermatomes
  • New bilateral radicular pain
  • Structural deformity – new, worsening, or symptomatic
  • Consider Malignant Spinal Cord Compression see MSCC Pathway

Specific red flag signs

Additional Cervical Red Flag Signs

  • Dizziness, Diplopia, Drop attacks, Dysarthria, Dysphagia 
  • Ataxia, Nausea, Numbness, Nystagmus 

Additional Thoracic Red Flag Signs

  • Thoracic pain  (band like pain or widespread neurology from thoracic level down)
  • History of TB

Additional Lumbar Red Flag Signs

  • New onset of Foot drop  

 

Differential diagnosis

Acute Cauda Equina Syndrome (CES) signs:

Discitis/infection symptoms:

  • Sudden onset of acute spinal pain or suspicious change in pattern, no history of trauma
  • Systemic signs, fever, high pulse  
  • Night pain  
  • All spinal movements grossly restricted by pain & spasm  

Degenerative Cervical Myelopathy:

  • Numbness/pins and needles/changes in sensation in the arms and/or legs
  • Clumsy hands, loss of finger dexterity causing difficulty with writing, shirt buttons, picking up small objects, fine motor skills
  • Muscle weakness or heaviness in the arms and/or legs
  • Imbalance, loss of co-ordination in your legs causing unsteadiness, trips or falls
  • Difficulty walking, legs feeling heavy, stiff or weak
  • Progressive/changing pain in the neck, arms and/or legs
  • Altered sensation around your back passage and/or genitalia
  • Changes to bladder function such as urgency/difficulty to pass urine or incontinence
  • Changes to bowel function or incontinence 
  • Erectile dysfunction

Inflammatory Spondyloarthropathy:  

Primary care management

No red flag symptoms

  • Provide reassurance; keep on the move, stay at work if possible.
  • Medicate as appropriate
  • Address any additional yellow flag signs:  
    • Attitudes & beliefs about back pain  
    • Behaviour  
    • Compensation issues  
    • Diagnosis & treatment  
    • Emotions  
    • Family  
    • Work 
  • Signpost to NHS inform (www.nhsinform.scot) if condition < 4 weeks duration

Versus Arthritis Decision Aid Tool   https://www.versusarthritis.org/about-arthritis/healthcare-professionals/musculoskeletal-decision-support-tools/

 

 

Physiotherapy referral

Signpost to physio via single access point (030 3333 3001) for:

  • Acute/acute on chronic LBP not settling in 4 weeks
  • Unilateral nerve root pain > 4 weeks
  • Symptoms of neurogenic claudication (Lumbar spinal stenosis)
  • No physio input in last 6 months 
  • Previous episode of physio management ended due to DNA 
  • Previous benefit from physio input 
  • Chronic spinal pain – if they have not had physiotherapy, for change in presentation/help to achieve specific functional goal (in absence of dominant psychological component)
  • GP referral to physio via SCI-Gateway is helpful if the patient has complex past medical history.
  • GP referral to physiotherapy if patient unable to use online resources/ cope with telephone triage via SAP 
  • Urgent GP referral to physio is appropriate for new onset unilateral radiculopathy without red flag signs.
  • Patients <16 yrs should be referred to paediatric services via SCI Gateway

Most mechanical neck and back conditions respond to physiotherapy intervention within 3 months 

Physiotherapist can refer to Orthopaedic Spinal Service:

  • If patient has symptoms of spinal stenosis significantly affecting quality of life 
  • Where there is no improvement in arm or leg pain, where neural tethering is clinically observed, and symptoms are significantly affecting quality of life  

Physiotherapist will liaise with GP if concerned about any concurrent problem or prescribing issue or if recommending Pain Management Service where psychosocial dominance or distress indicates a multi-disciplinary team management approach 

All physiotherapy records are available on clinical portal.

 

Refer to other services

Refer immediately by calling orthopaedic on-call

Refer immediately

Recent onset (<2 weeks) back or leg pain and any of:

  • New difficulty initiating micturition or impaired sensation of urinary flow
  • New altered perianal, perineal or genital sensation - subjectively reports or objectively tested
  • Severe or progressive neurological deficit of both legs such as major motor weakness with knee extension, ankle eversion or foot dorsiflexion
  • New loss of sensation of rectal fullness
  • New sexual dysfunction (loss of erection or ability to ejaculate, loss of vaginal sensation)
  • Suspected infection/discitis - see differential diagnosis above

Ensure symptoms and signs above including duration are clearly communicated to the receiving clinician and documented in primary care notes.

Refer to orthopaedics via SCI-Gateway ... back pain for the following:

Refer urgently

  • New foot drop
  • New onset bilateral arm or leg symptoms
  • Cauda equina syndrome > 2 weeks
  • Degenerative cervical myelopathy
  • Severe/worsening radicular leg/arm pain with associated abnormal strength, sensation or reflexes despite optimal use of neuropathic medication +/- physiotherapy
  • If history of cancer consider malignant spinal cord compression

Refer routinely

  • >8/52 history of radicular leg or arm pain without any improvement despite conservative treatment i.e. neuropathic medication and physiotherapy
  • Neurogenic claudication (spinal stenosis) with restricted walking distance and function
  • Non specific LBP which has failed to respond to physiotherapy and conservative management where patients wish further input and opinion on management
  • Patients with features of specific causes of pain i.e. Spondylolisthesis, spondylolysis where investigations would guide management

Refer to other services

  • Inflammatory Spondyloarthropathy - if this is suspected please consider a referral to Rheumatology with a current ESR/CRP​​.​
  • New onset of back pain <18 y/o refer to Paediatric Orthopaedic Consultant​​​
  • New onset of back pain >55 with osteoporotic risk factors - please refer to the Osteoporotic Pathway​​​

Self-management resources

Patients can self refer to MSK physio by calling the Single access point - 030 3333 3001.

Other self management resources:

Editorial Information

Last reviewed: 22/03/2023

Next review date: 22/03/2024

Author(s): Deena Dean.

Reviewer name(s): Deena Dean.