1) Younger than 20 yrs at the onset (discitis, congenital vertebral anomalies)
2) Older than 55 yrs at the onset (Mechanical backache unlikely, tumors and cancer likely, compression fracture from osteomyelitis)
3) Backache followed major trauma (fall from a height or RTA) to the spine
4) Pain is constant and/or progressive and/or severe and/or lack of trauma (spinal pathology like infection, tumor inflammation or referred pain)
5) Pain at the back of the chest
6) P/H or current cancer (malignant backache)
7) Using steroids now
8) Alcohol or Using illegal drugs – IV drug use (increased incidence of osteomyelitis, trauma, fracture)
9) HIV now
10) Systemically unwell with fever, chronic infection like UTI, skin infections
11) Loss of weight more than 5 kg or 10% of body weight in 3-6 months
12) Difficulty in bending forwards
13) Leg weakness, tingling or numbness
14) Obvious spinal deformity
15) Unexplained backache in a female with abdominal and/or VE mass (exclude ovarian Ca if not due to fibroids, GIT, or GUS masses)
16) Unexplained backache in a male do a DRE and OSA to exclude prostate Ca
17) Persistent back pain in a child or young person (FBC, BF)
18) Unexplained backaches in a child with Down syndrome, neurofibromatosis (FBC, BF)
19) Backache with evidence of hypotension like collapse, sweatiness, pallor (? Leaking abdominal aortic aneurysm, hypertensive patient with abdominal aortic aneurysm)
20) Very severe backache with no evidence of lumbar spine painful movements or limitation of movements – very severe backache with painless spinal movements (? Leaking abdominal aortic aneurysm)
21) Thoracic pain
22) Pain radiating down both legs OR any disturbance of motor power (upgoing plantars, gait disturbances), bladder or bowel function (loss of sphincter tone, altered S4 sensation) (immediate referral to hospital to exclude cauda equina syndrome)
24) Gradual onset before 40 yrs, marked morning stiffness, persistent limitation of spinal movement in all directions, peripheral joint involvement (arthritis type of backache with spondylitis)
25) Pain at rest (rules out mechanical cause for backache)
26) Bilateral sciatica OR bladder or bowel dysfunction (cauda equina)
27) Any 1 of the following diseases – alcoholism, anorexia nervosa, breast cancer, celiac disease, diabetes, immobility and bed rest, IBD, lactose intolerance, osteoarthritis, rheumatoid arthritis, SLE – these are risk factors for osteoporosis
28) Any bladder OR gait dysfunction with backache excludes cauda equine syndrome which is a neurosurgical emergency
29) Past OR Current – cancer, TB, HIV, IV drug abuse, Osteoporosis,
30) Night pain (Infections and tumors more likely and mechanical causes lessen nocte)
31) Bilateral paresthesiae in hands and/or feet
32) Blood in sputum.
33) Bilateral or unilateral radiculopathy
34) Numbness and paresthesiae in the perineal region
42) Recent bowel or bladder changes (cauda equine, compression or other myelopathy)
43) Unexplained neurological deficits (Gullian Barre, stroke, head injury)
44) Age > 50 And long-term corticosteroid use (spinal compression fracture)
45) Failure of conservative reatment And unexplained weight loss And Cancer history And Age geater than 50 (virtually 100% sensitive to spinal maligancy)
46) Sudden onset change of bowel or bladder control (retention on incontinence) (Cauda equina syndrome – requires emergent evaluation and surgery)
47) Sudden onset loss of bowel or bladder control (retention on incontinence) (Cauda equine syndroma – requires emergent evaluation and surgery)
48) Unexplained change of bowel or bladder control (retention on incontinence) (Cauda equina syndrome – requires emergent evaluation and surgery)
49) Unexplained loss of bowel or bladder control (retention on incontinence) (Cauda equina syndrome – requires emergent evaluation and surgery)
50) Sudden onset or otherwise unexplained bilateral leg weakness (Cauda equine syndrome)
51) Saddle area numbness (Cauda equina syndrome)
52) Extremely severe backache in an elederly person without any spinal signs (exclude abdominal aortic aneurysm)