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Back Pain? Watch out for Red Flag Symptoms

Patients presenting with back pain represent a large portion of my weekly medical cases.  Though most cases improve with strengthening, flexibility, or basic physical therapy, more serious conditions can present with seemingly mild back pain.

  “RED FLAG” Back pain symptoms

These symptoms indicate potential for a serious back problem that you should seek formal evaluation.

    1. History of cancer
    2. Abdominal pain
    3. Unexplained weight loss >10 kg within 6 months
    4. Age over 50 years or under 17 years old
    5. Failure to improve with therapy (As described above)
    6. Pain persists for more than 4 to 6 weeks
    7. Night pain or pain at rest
    8. Urinary Incontinence or retention
    9. Saddle anesthesia: Numbness in the groin or rectal area
    10. Anal sphincter tone decreased or Fecal Incontinence
    11. Bilateral lower extremity weakness or numbness
    12. Progressive neurological deficit


In my clinical experience, the above symptoms only present in 5 % or so of cases I see yearly.  However, because back pain is so common, that represents a considerable number of individual patients annually.  By ignoring the above, or worse yet, using strong narcotic medications without appropriate workup, one can miss a life-threatening problem.


Common Tests to Evaluate “RED FLAG” Back Pain


All these tests are not necessary to work-up your particular type of back pain.  The following list however should help orientate you to the diseases a physician hopes to either diagnosis or exclude.


  1. CBC: (Complete Blood Count) Anemia, cancer, leukemias, and lymphomas often present with abnormalities in this test.  It serves as a basic point of reference during the back pain workup
  2. CMP: (Complete Metabolic Panel) A general chemistry panel that looks at electrolytes, kidney function, liver function, and importantly calcium and serum protein levels.  Again, much like a CBC, this panel helps screen for general diseases or imbalances that can explain back pain.
  3. Urinalysis: Kidney stones, kidney disease, bladder infections, prostate disorders can all present with back pain.
  4. ESR:  (Sedimentation Rate)  Blood test that looks for general immune inflammation.  It individually means nothing except “Inflammation.”  However, if the ESR is high in a back pain workup, the physician must seek greater explanation.  If auto-immune conditions contribute to back pain, the sedimentation rate can also be high.  (Ankylosing spondylitis, Rheumatoid Arthritis, etc.)
  5. Xrays:  Good for determining presence of fractures, arthritis, and misaligned joints.  Usually a basic screening test
  6. MRI:  Very detailed image that allows visualization of soft tissue, nerves, discs, and ligament structures.  Usually MRI’s are used in the presence of active neurological findings.  Importantly, MRI’s often uncover structural findings that while technically abnormal, play no role in the cause of their back pain.
  7. CT:  High quality image that often gets used to evaluate bone anomalies, as well as inter-abdominal causes of back pain such as: Kidney stones, masses, tumors, cancers, etc.


I hope this information helps you make a more informed decision about seeking care for such a common problem–Back pain.




  • 85% of the US population suffers from back or neck pain at some point in their lives.1
  • Back pain is the leading cause of disability in Americans under 45 years old.2
  • Back pain is the third leading cause of disability in people over 45 years of age. 2
  • More than 26 million Americans between the ages of 20-64 experience frequent back pain.2
  • Americans spend at least $50 billion* each year on back pain-and that’s just for the more easily identified costs.4
  • Back pain is the second most common reason for seeing a doctor in the US, following coughs and other respiratory infections.2
  • Back pain is the third most common reason for surgery.2
  • Failed back surgery syndrome is seen in 10-40% of patients who undergo back surgery. It is characterized by intractable pain and varying degrees of functional incapacitation occurring after spine surgery. More risks include infection, nerve damage, deterioration of health and post operative complications. 3
  • Fewer than 5% of people with back pain are good candidates for surgery.4
  • According to a recent article in the USA TODAY, “The U.S. health care system spends about as much each year on spine problems as it does on cancer.”


  1. Orthopedic Clinics of North America, Volume 35, Issue I, Pages 1-5 S. Pai, L. Sundaram
  2. Bigos S, et al. Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14. Rockville, MD: U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Dec. 1994.Eyerman, Edward MD. Journal of Neuroimaging. June 1998
  3. In Project Briefs: Back Pain Patient Outcomes Assessment Team (BOAT). In MEDTEP Update, Vol. 1 Issue 1, Agency for Health Care Policy and Research, Rockville, MD, Summer 1994.
  4. John P. Kostuik, MD, and Simeon Margolis, MD, Ph.D. Low Back Pain and Osteoporosis. The John Hopkins White Paper on Low Back Pain and Osteoporosis, 2002.


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