Serious lumbar spine conditions (Red Flags)

From the neurosurgical point of view, these include (See referral guidelines):

• Suspected cauda equina syndrome
• Acute foot drop
• Suspected infection
• Suspected vertebral fragility fractures (VFF Pathway)
• Deteriorating lumbar radiculopathy
• Suspected metastatic spine cord compression/ other malignancy
• Suspected infection
• Suspected vascular symptoms
• Widespread neurology with features not in keeping with lumbar radiculopathy

Suspected cauda equina syndrome

Red flags include:

• Bilateral sciatica – sudden onset bilateral radicular pain, or unilateral radicular pain, that has progressed to bilateral
• Severe or progressive bilateral neurological deficits of the legs such as major motor weakness with knee extension, ankle everson or foot dorsiflexion
• Difficulty initiating micturition or impaired sensation of urinary flow, if untreated this may lead to irreversible
  • urinary retention with overflow urinary incontinence
• Loss of sensation of rectal fullness, if untreated this may lead to
  • irreversible faecal incontinence
• Perianal, perineal or genital sensory loss (saddle anaesthesia or paraesthesia)
• Laxity of the anal sphincter
• Sexual dysfunction – inability to achieve erection or to ejaculate, or loss of genital sensation.

Acute foot drop

Foot drop is a symptom of a variety of disorders and can be classified as either a central or peripheral problem. Peripheral problems can be differentiated into peripheral neuropathy or radiculopathy.

Foot drop from a spinal source causes weakness due to compression of L4 and/or L5 nerve roots causing weakness predominantly in the tibialis anterior muscle and characteristic slapping gait (high stepping gait).

• Foot drop is classified as weakness of Dorsiflexion grade 3 or less (Oxford scale).
• There is no current agreed timescale that would define an acute episode.
• For acute cases early opinion is considered essential to see if surgery is indicated.
• Consideration for Surgery is based on a number of factors including duration since onset, grade of power, age, medical fitness and patient’s preference.

Referral- Discuss with on call neurosurgical registrar via switchboard 0131 242 1000

Suspected metastatic spine cord compression (MSCC)

Consider the possibility of spinal metastases or MSCC in people who have the following features and immediately follow MSCC pathway if patient has cancer (or strongly suspected) or is under follow up from a previous cancer and one of the following:

• Severe, intractable progressive pain, especially thoracic
• New spinal nerve root pain (burning numb, shooting)
• Any new difficulty walking
• Reduced power/ altered sensation in limbs
• Bowel/ bladder disturbance.

Lothian Metastatic Spinal Cord Compression Pathway – Available at: MSCC Intranet Page

Please Note: Separate documents available for NHS Lothian & NHS West Lothian – Please select appropriate depending on work area.

Referral/ action- see detail within  RefHelp Metastatic Spinal Cord Compression Page

Deteriorating lumbar radiculopathy with motor deficit grade 3 or less (Oxford scale)

Referral- Discuss with on call neurosurgical registrar via switchboard 0131 242 1000

Suspected infection

Such as discitis, vertebral osteomyelitis, or spinal epidural abscess.

Red flags include:

• Fever
• Tuberculosis, or recent urinary tract infection
• Diabetes
• History of IV drug use
• HIV infection, use of immunosuppressants, or the person is otherwise immunocompromised.

Referral- Discuss with on call neurosurgical registrar via switchboard 0131 242 1000

Suspected malignancy

Red flags include:

• Person being 50 years of age or more
• Gradual onset of symptoms
• Severe unremitting pain that remains when the person is supine, aching night pain that prevents or disturbs sleep, pain aggravated by straining (eg at stool, coughing, sneezing) and thoracic pain
• Localised spinal tenderness
• No symptomatic improvement after 4-6 weeks of conservative low back pain therapy
• Unexplained weight loss
• Past history of cancer- breast, lung, gastrointestinal, prostate, renal, thyroid cancers are more likely to metastasize to the spine.

If clinical assessment by GP leads to a very strong suspicion of suspected underlying malignancy, consider recommendations and referral options GP Access to CT for Suspected Cancer (No Clinically Obvious Primary) – RefHelp

Suspected vascular symptoms

Clinical features of Intermittent Claudication see guidance on Intermittent Claudication RefHelp page

Clinical features of Abdominal Aortic Aneurysm see guidance on Abdominal Aortic Aneurysm RefHelp page

Widespread neurology- features not in keeping with lumbar radiculopathy

See Neurology – RefHelp for further referral guidance and support