Back Pain serious pathology causes and red flags are something we need to consider every time someone presents with pain. As a veteran Physiotherapist and progressive educator and consultant, I’m all about the evidence when it comes to back and neck pain, and today it’s time for the red flags or in layman terms, serious pathology signs and symptoms.
We will cover the latest evidence/data and I offer you a completely free guide that uses this evidence to work out whether you have significant signs of serious pathology of the spine. So if you don’t fancy reading heavy data just click on the link for the SpinalRisk red flag tool.
Back pain is everywhere and people are in serious pain. They want pills, they want quick fixes, they want to zap themselves with cattle prods, they want strange people to manhandle them in baby oil! But first of all they want to know if it’s not a sign of something far more sinister.
This article could save yours or someone else’s life. It isn’t here to alarm you but rather to present the facts that show that while in some cases spinal pain can be very serious; the bulk of back and neck pain is most likely not from serious pathology.
A wee story first:
Spinal pain can be serious.
Let me tell you of a young chap who had some moderate back pain but also had severe constipation, erectile dysfunction and was losing his bowels in his pants three times per week. Doesn’t sound too flash does it?
As a fit, educated 25-year-old he thought this was just a passing symptom phase and that he could “work through it”! So he didn’t take time off work, refused to go to hospital and get immediate medical attention.
We all know these types, who seem to be in self-destruct mode by working themselves into an early grave or being unable to give themselves time to gather their thoughts and rationality.
He had Cauda Equina Syndrome whereby the lower spinal cord is impeded causing possibly permanent damage to the nerves going down your private regions/fun parts.
Moreover, he suffered psychological trauma also as he feared having a sexual relationship, worried about being able to ever have children and had the embarrassment of crapping his pants in public. He would most likely have had some serious medical intervention and possibly surgery within 48 hours if he’d taken the correct advice that he’d been given long before he arrived in my consultation.
My point is that back or neck pain can be the sign of serious medical issues. Like fractures, cancer, kidney infections or even a burst appendix.
So when dealing with people with spinal pain we must consider these things every time, yet many clinicians do not understand the risks fully and fail to ask appropriate questions to decide whether there is a major risk of serious pathology of the spine.
Traditionally, Doctors like to think they are the only ones to have the skills to accurately highlight symptoms that require further investigation, but the fact is that red flag questions used by Doctors remain largely not backed up by evidence (Verhagen et al., 2016).
Even more concerning is that many Doctors are found to ignore the guidelines set by the researchers, and send people for lots of unnecessary scans of the spine. This in turn can then lead us down a path of unnecessary radiation, stress, fear, inappropriate treatments and even surgeries that we don’t need.
But First, Let’s Talk About the Serious Stuff That Can Cause Back Pain
The Back Pain Serious Pathology Risk Data (as presenting to Medical Facilities)
The way I’ll do this is to tell you what the pathology is, what some of the typical symptoms and signs are in the research, then give the percentage of people in a certain population that test positive for the condition. That is the prevalence.
Please note these percentages are from studies coming from different clinical settings. So the higher percentages usually come from back pain presentations in Emergency or Specialist Back clinics whereas the lower percentage findings invariably come from Primary care – i.e. family/general practitioner/Physio clinic settings.
Think of it like this — the back specialist who only sees chronic back pain patients and complex cases is far more likely to see someone with cancer of the spine rather than your local GP who is dealing with runny noses and toenail fungus.
Serious Pathology Back Pain Causes
Spinal Malignancy (Cancer)
Spinal malignancy is cancer of the spine, think tumours, malformations affecting bones, cartilage, soft tissues, nerves. These can be primary tumours or secondary/metastatic tumours.
Symptoms and signs to look for can include:
- History of any type of cancer
- Significant unexplained weight loss
- Pain at night when resting
- Being over 60 years of age
Prevalence rates:
0.0 – 0.7% for back pain presentations in primary care,
0.1% in ED,
1.6 – 7% in spinal clinics.
Spinal Fracture
A spinal fracture is a break in any bone of the spine, whether it be from trauma like a car accident or from pathological fractures caused by conditions like osteoporosis where the bone becomes more brittle and less dense.
Signs and symptoms of note:
- Major or significant trauma (e.g. fall >1 m or 5 stairs, vehicle accident, blunt trauma)
- History of previous osteoporotic fractures
- Thoracic pain (>70% of non-traumatic spinal fractures and metastatic fractures)
- Use of steroids or immunosuppressive drugs > 3 months
- Being female aged 50 – 70 years (12% osteoporotic fracture prevalence)
- Being female >70 years (20% osteoporotic fracture prevalence)
Prevalence rates:
Osteoporotic fractures – 0.7 – 4.5% in back pain presentations in primary care; increases to 5.6% in spinal clinics.
Traumatic fractures – less than 1% in primary care.
Cauda Equina Syndrome
This is like the case mentioned earlier, where something causes narrowing or damage of the lower spinal cord leading to pain, loss of sensation, bladder and bowel issues, sexual function issues, and weakness in the legs.
Signs and symptoms of note:
- Saddle anaesthesia (numbness/loss of sensation)
- Bladder and/or bowel dysfunction
- Leg weakness
- Bilateral leg pain
Prevalence rates:
0.04% of total back pain presentations
0.4% in spine clinics
Even in specialist clinics, the rates are very low for Cauda Equina Syndrome as a back pain serious pathology presentation.
Infection of the Spine
Infection of the spine can be bacterial, fungal, or viral, affecting the spinal cord, vertebrae, or surrounding tissues. It can come from blood infections, trauma, spread from other parts of the body, or as a result of surgical procedures.
Signs and symptoms to look out for:
- Fever or chills
- Pain at night
- Recent infection history
- Use of steroids or immunosuppressors > 3 months
- IV drug usage
Prevalence:
0.01% in primary care
1.2% in specialist spine clinics
Scoliosis of the Spine
Scoliosis is a sideways curvature of the spine which can be caused by genetic, neuromuscular, or degenerative conditions — or can occur idiopathically (without a known cause).
The prevalence rates are highly variable. Many people have mild, pain-free scoliosis that’s not a serious pathology. It’s a debatable red flag unless severe.
Prevalence data:
2–3% of the U.S. population (AANS).
3.1% of children and adolescents (Li et al., 2024).
Family doctors play an important role in monitoring spinal curvature in children, as early management can help immensely.
Elderly:
Rates rise dramatically — 15–68% in those over 60 years (Ames et al., 2016).
Neurological or Nerve Pathology
You’ll note I didn’t list neurological or nerve pathology as a red flag in low back pain — and many researchers don’t. That’s because a high percentage of people with low back pain have a nerve-related component.
One study found 47%, others up to 90% (Gudala et al., 2017).
That said, if you have severe pins and needles, numbness, or leg weakness, that should be addressed immediately by a skilled clinician — but doesn’t necessarily mean you need a spinal scan.
For example, I experience sporadic tingling in two arm nerves (thanks, rugby), but since I rarely get pain or movement limitation, I’ve never had them scanned. If I suddenly couldn’t do a Muay Thai elbow, then I’d get that scan done.
In Summary
Serious pathology presentations are very low in people with back pain.
This means that only a small number of people with significant symptoms should be sent for X-rays, CT scans, or MRI.
If you want to read my next article on neck pain red flags, hit the link below or click on the right to get my FREE SpinalRisk Red Flag Checker Tool — based on the latest studies and combinations of symptoms and signs — the same tool I use for my patients.
One thing I should mention is that for red flag screening, it’s the combination of signs and symptoms that increases the risk of serious pathology. That’s what I’ve tabled in my SpinalRisk Tool — a fertile area for further scientific investigation.
If anyone wants to contact me about turning SpinalRisk into a digital app, let me know via email — I’m making this happen for the benefit of patients, clinicians, and health systems.
Check out the current version in the column on the right — it’s free and I hope it helps you in some way.
Please consider my online course and guides here if you need to get to the bottom of your neck pain — or if you or your organisation would like a consultation, book here.
Cheers,
Stuart Cox
Bibliography
Ames, C. P., Scheer, J. K., Lafage, V., Smith, J. S., Bess, S., Berven, S. H., Mundis, G. M., Sethi, R. K., Deinlein, D. A., Coe, J. D., Hey, L. A., & Daubs, M. D. (2016). Adult spinal deformity: epidemiology, health impact, evaluation, and management. Spine Deformity, 4(4), 310–322. https://doi.org/10.1016/j.jspd.2015.12.009
Ankylosing Spondylitis : Symptoms, Diagnosis and Treatment. (n.d.). Retrieved March 27, 2025, from https://www.hopkinsarthritis.org/arthritis-info/ankylosing-spondylitis/
Béjot, Y., Daubail, B., Debette, S., Durier, J., & Giroud, M. (2014). Incidence and outcome of cerebrovascular events related to cervical artery dissection: the Dijon Stroke Registry. International Journal of Stroke, 9(7), 879–882. https://doi.org/10.1111/ijs.12154
Cho, S. K., Safir, S., Lombardi, J. M., & Kim, J. S. (2019). Cervical spine deformity: indications, considerations, and surgical outcomes. JAAOS, 27(12), e555–e567. https://doi.org/10.5435/JAAOS-D-17-00546
Finucane, L. M., Downie, A., Mercer, C., Greenhalgh, S. M., Boissonnault, W. G., Pool-Goudzwaard, A. L., Beneciuk, J. M., Leech, R. L., & Selfe, J. (2020). International framework for red flags for potential serious spinal pathologies. JOSPT, 50(7), 350–372. https://doi.org/10.2519/jospt.2020.9971
Gudala, K., Bansal, D., Vatte, R., Ghai, B., Schifano, F., & Boya, C. (2017). High Prevalence of Neuropathic Pain Component in Patients with Low Back Pain: Evidence from Meta-Analysis. Pain Physician, 20(5), 343–352.
