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Back Pain Red Flags: Warning Signs and When to Get Help
Short answer: Most back pain is not caused by a serious problem, and much of it gets better within a few weeks [1]. But some symptoms are warning signs, often called red flags, that mean you should be checked by a doctor. The most urgent are new trouble controlling your bladder or bowels, numbness around the genitals, buttocks or inner thighs, and weakness or numbness in both legs. If you have any of these, go to a hospital emergency department straight away.
Key takeaways
- A red flag is a reason to get checked. It is not a diagnosis.
- Having a red flag does not mean something serious is wrong, and having none does not guarantee that nothing is. If you are worried, see a doctor.
- Some symptoms need emergency care. Others need a doctor soon, but not necessarily the same hour.
- Back pain can sometimes come from the chest, abdomen or other organs, not only from the spine or muscles.
- This page cannot diagnose you. Only a doctor who examines you can do that.
What are back pain red flags?
A red flag is a symptom, or a detail in your health history, that makes doctors look more carefully for a serious cause of back pain. Serious causes are uncommon. They include a broken bone, pressure on the spinal cord or the bundle of nerves at the base of the spine, infection, and problems with the blood vessels [1].
Red flags are a guide, not a test:
- In a study of about 1,200 people in primary care clinics in Australia, more than 80% had at least one red flag, but fewer than 1% were found to have a serious cause [1].
- In one review of people with cancer of the spine, around two-thirds had no red flags beforehand [1].
So the list below is a way to decide when to seek help. It is not a way to rule a serious problem in or out at home.
Emergency signs: go to a hospital emergency department now
Get emergency care if you have back pain together with any of these:
- New difficulty controlling your bladder or bowels, or difficulty passing urine [3][4].
- Numbness or tingling around your genitals, buttocks, inner thighs or back passage [2][3][4]. Some health services also mention a changed feeling when wiping after using the toilet [2].
- Weakness, numbness or tingling in both legs, or in a leg and getting worse [2][4][5].
- Difficulty walking, or legs that feel weak or give way [6][7].
- Changes in sexual function or sensation [4][5].
- Chest pain or breathlessness [5][6][8]. Pain that seems to come from the back can sometimes come from the heart, lungs or blood vessels instead [1].
- Sudden, severe pain in the back, side or belly, especially if you feel faint [1].
- Back pain after a serious accident or fall [3][4][6][8].
The first group of symptoms, involving the bladder, bowels and the area around the genitals and buttocks, can be signs of pressure on the nerves at the base of the spine. This is called cauda equina syndrome. In problems like this, time matters, so do not wait to see whether it passes [1].
Signs to see a doctor soon
Contact a doctor promptly, the same day if you can, if your back pain comes with any of these:
- A fever of 38°C or higher, or feeling generally unwell [3][4][6][9].
- Unexplained weight loss [3].
- A past history of cancer and new back pain [1][2].
- Pain after a fall or injury, even a minor one [3][8]. Tell your doctor if you have weak bones.
- Pain that is constant, does not ease when you lie down, or is worse at night or wakes you [3][6].
- Swelling or an obvious change in the shape of your back [3].
- Pain high up in the back or in the chest [3].
- Numbness, pins and needles or weakness in a leg that is getting worse since the back pain started [2].
- Pain that goes down the leg below the knee [3].
- A recent spinal injection or operation, a recent infection, or a condition that lowers your immunity, such as diabetes [1].
- Pain that painkillers do not relieve [1].
- Severe back pain for the first time when you are over 50, or when you are under 18 [1][8].
- Pain that is getting worse, or has not improved after about six weeks [8].
This list is not complete, and you do not need to have one of these symptoms to see a doctor. If something feels wrong to you, get it checked.
Is it muscle or an organ?
You cannot reliably tell at home. Most back pain comes from the muscles, joints, discs or nerves of the back [1]. But back pain can also come with problems elsewhere in the body. Health services list chest pain, stomach pain and fever as reasons to seek help when you have back pain [6][8], and some serious problems of the blood vessels can first show up as back, side or belly pain [1].
If your back pain comes with chest pain, breathlessness, belly pain, fever or feeling very unwell, do not try to work out the cause yourself. Get medical help.
Middle back pain
The middle of the back lies between the base of the neck and the bottom of the ribs. The same warning signs apply to it, including weakness or numbness in both legs, difficulty walking, numbness around the genitals or buttocks, and trouble with the bladder or bowels [7]. If middle back pain comes with chest pain or breathlessness, treat it as an emergency.
What does a doctor do?
A doctor will ask about your symptoms and health history, and will usually examine your back and legs, including strength, sensation and reflexes. Most people with back pain do not need an X-ray or scan. These tests are used mainly when a serious cause is suspected [1]. Your doctor decides which tests, if any, you need.
What not to do
- Do not wait and see if you have any of the emergency signs above.
- Do not keep taking painkillers to cover up warning signs. Pain that painkillers do not relieve is itself something to mention to a doctor [1].
- Do not wait for a camp or an appointment if you have emergency symptoms. Go to the nearest hospital emergency department.
How The Spine Foundation can help
If you have back pain that keeps returning, comes with leg symptoms, or worries you, a proper assessment can help. The Spine Foundation provides spine care and runs camps across India. Find a spine care centre near you or contact our team to ask about upcoming camps.
Our camps are not an emergency service. If you have any of the emergency signs described above, go to the nearest hospital emergency department now.
This article is for general information only and is not a substitute for medical advice, diagnosis or treatment. Always speak to a qualified doctor about your own condition.
Frequently Asked Questions
How do I know if back pain is serious? You cannot be certain without a doctor, but warning signs include trouble controlling your bladder or bowels, numbness around the genitals or buttocks, weakness or numbness in both legs, fever, unexplained weight loss, pain after an injury, and constant pain that does not ease with rest. See the lists above.
Does a red flag always mean something serious? No. In a large study of people with back pain, most had at least one red flag but very few had a serious cause [1]. A red flag means it is worth getting checked.
How do I know if my back pain is muscle or organ? You cannot reliably tell at home. Back pain with chest pain, belly pain, breathlessness, fever or feeling very unwell needs medical attention [6][8].
What could be causing my back pain? Most back pain is called non-specific or mechanical, which means it is not linked to one serious cause. Pain that travels down a leg can come from an irritated nerve. A small number of cases have an emergency cause, such as a fracture, pressure on the spinal cord or nerves, infection or a blood vessel problem [1]. A doctor can tell you which applies.
What could be causing a dull pain in the middle back? There are many possible causes, and a doctor needs to examine you to find out. If it comes with chest pain, breathlessness, fever or weakness in the legs, get urgent medical help [7].
When should I see a doctor for back pain? See a doctor promptly if you have any of the signs listed above. Also see one if your pain is getting worse or has not improved after about six weeks [8].
References
- Sikina M, Kiel J. Re-evaluating red flags for back pain. American College of Emergency Physicians, Sports Medicine Section; August 2022. acep.org
- Northamptonshire Healthcare NHS Foundation Trust. Back pain: urgent symptoms check. nhft.nhs.uk
- Gloucestershire Hospitals NHS Foundation Trust. Red flags in back pain. gloshospitals.org.uk
- St George’s University Hospitals NHS Foundation Trust. Back pain advice (patient information). stgeorges.nhs.uk (PDF)
- NHS. Check if this is the right service for you (back and joint problems). nhs.uk
- University of Sheffield Health Service. Low back pain. sheffield.ac.uk
- Berkshire Healthcare NHS Foundation Trust. Mid-back pain. berkshirehealthcare.nhs.uk
- CISSS de la Côte-Nord (Québec). Back pain: health fact sheet. cisss-cotenord.gouv.qc.ca (PDF)
- NHS Fife. Cauda equina syndrome: warning signs. nhsfife.org
