When you should see a doctor about head, neck, or back pain

Matt had suffered from back pain on-and-off for years. He’d been in a car accident years ago and had also survived a nasty fall from a ladder. The past few years had been pretty good, though, with only occasional low back pain after hard workouts. 

This recent slip from a ladder was different. And stupid, Matt said, because, in his hurry to clean out the gutters on a sunny day, he’d failed to secure the ladder properly.

Matt said he felt strange the next morning – while his back hurt, his left leg felt wobbly like Jello. He’d nearly tripped over his foot on his way to the bathroom. And, he’d had difficulty urinating when he did make it to the bathroom.

I asked him to look at a written list of other, more embarrassing symptoms, and let me know if he’d noticed anything of those issues. He answered yes, and pointed to the question that read, “Do you have trouble getting an erection?” He said that was not normal. 

Matt had reported several “red flag” symptoms that indicated his back pain might be different – and more serious – this time around. Red flags describe warning signs of more severe injuries or other conditions such as infections or tumors. Testicular cancer, for example, can cause back pain if cancer spreads to areas on the back (inner) side of the abdomen.  

Despite the alarming terminology, red flag symptoms are not proof of a severe condition. The body’s reaction to illness or disease is often complicated. Two people with the same problem can have very different symptoms.  And, some people can have a serious situation developing with no apparent symptoms at all. 

However, in our experience, some red flags should spark a sense of urgency. One or more of the following symptoms warrants urgent investigation by a physician (medical doctor): 

Red flags for neck pain and headaches

  • Loss of grip strength, or noticing you’ve started dropping things
  • Bursting, stabbing or “thunderclap” head pain
  • Feeling like a headache is the worst you’ve ever had
  • Headaches brought on during workouts, coughing, or when having sex

Red flags for back pain

  • Unexplained leg weakness causing falling or difficulty walking
  • Loss of feeling in one or both legs
  • Numbness in the groin area, aka “saddle anesthesia”
  • Unexpected erections problems
  • Loss of bowel or bladder control, or new difficulty in urinating

Other symptoms – unexplained body pain along with:

  • Fever or chills
  • Prolonged illness
  • Recurring pain at night
  • Unexpected weight loss (for example, 5% bodyweight in under a month)
  • Steroid or intravenous drug use 

A serious diagnosis with a happy ending

 I referred Matt to his primary care doctor with concern for cauda equina syndrome. This diagnosis was confirmed by a neurosurgeon, and Matt had urgent surgery to relieve the pressure on his spinal nerves. Though I know his leg strength and walking has returned to normal after the procedure, I haven’t asked him about sexual function. I’m assuming by his generally happy demeanor that all is well!

Key Points

  • Red flags are warning signs that an injury may be severe, or that another type of (non-mechanical) illness could be present.
  • If you have head, neck, or back pain along with red flags, contact your primary care provider or medical doctor or go to an urgent care facility.
  • If you have pain without any of these red flags, or the pain has been around a while, you can schedule an appointment at a time that’s more convenient for you. A physical therapist, physician, or other healthcare provider trained in musculoskeletal medicine is a good option.
  • Don’t wait to communicate – even a simple phone call can provide a valuable connection with a healthcare professional who can help you decide what to do or who to see next.

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Vijiaratnam N, Williams DR, Bertram KL. Neck pain: What if it is not musculoskeletal? Aust J Gen Pract. 2018; 47(5):279-282.

Tsiang JT, Kinzy TG, Thompson N, et al. Sensitivity and specificity of patient-entered red flags for lower back pain.  Spine J. 2019;19(2):293-300.

Premkumar A, Godfrey W, Gottschalk MB, Boden SD. Red flags for low back pain are not always really red; A prospective evaluation of the clinical utility of commonly used screening questions for low back pain. J Bone Joint Surg Am. 2018;100(5):368-374. 

Leerar PJ, Boissonnault W, Domholdt E, Roddey T. Documentation of red flags by physical therapists for patients with low back pain. J Man Manip There. 2007;15(1):42-49.

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