Red Flags

The Signs, RED FLAGS, Ages, & Groups

This section of the web site is extremely long and covers 2 parts.  We apologise in advance for this but it is important.  as we

need to fully explain the significance of the red flags and the consequences when Doctors and Emergency Room personel,

do not know the results of a misdiagnosis of Cauda Equina Syndrome. A misdiagnosis of Cauda Equina is not only

Dangerous but can be  very debilitating and life changing for the patient as you will see in this section. 


Adjustment, Rehabilitation, and Compensation. 

Cauda Equina Syndrome (CES) is a rare but serious condition. In the majority of cases, it is caused

by a disc herniation in the lower back that causes the Cauda Equina - a bundle of nerveslocated at the

top of the Lumbar Spine - to be compressed. 

The symptoms of Cauda Equina Syndrome in some cases can come on slowly, but the worst. kind of

Cauda Equina Syndrome occurs suddenly. Although most disc herniations present with pain, a really

bad disc herniation can cause a Cauda Equina Syndrome within six to 10 hours.

In some severe cases, Degenerative Disc Disease (DDD) can cause nerve problems in the feet. An

intervertebral disc can also herniate and push on the nerves that lead to the feet, causing pain and

sometimes tingling or numbness. The Cauda Equina can be found in the bottom third of the

spinal canal and from the T12/L1 vertebrae to the coccyx, beyond the conus medullaris into the lumbar



This shows the outcome of CES and its problems. Anyone of the symptoms shown can start your journey

to a hideous and painful disorder.  This a more detailed breakdown will help you understand more about



What Nerves and Vertebrae/Discs Affect What Areas

Note: Some of the information may be repeated in earlier Sections/Chapters. We cannot stress enough

that Cauda Equina is dangerous thus we keep hammering home the need for the medical profession to

be alert of the REFLAGS.

The Cauda Equina Syndrome Association (CESA) is just one of many organisations who are here here for people like

Claude and their families, carers and friends. We aim to embrace people living with CES and by using our collective

voice, we hope we will bring about change and an end to unnecessary suffering. The UK has the highest incidence of

CES. With the help of our members, we hope to change this and empower and support people to continue to live

positive, happy lives. 

The charts show the nerves and muscles controlled by the Cauda Equina on the pages following Parathesia is

discussed and what can cause this medical problem.  Admittedly we touch on most of these previously but

it requires to bring new medical problems along. (As shown in the chart in Part One Chapter Three of the

Book). Is defined as an abnormal sensation of the body, such as numbness, tingling, or burning.  These

sensations may be felt in the fingers, hands, toes, or feet. Depending on the cause, the sensation

of paraesthesia can be short-term and disappear quickly, such as when it occurs due to hyperventilation,

an anxiety attack or from lying on the arm while asleep. 

 Most people have experienced temporary paraesthesia, a feeling of pins and needles, at some time in their

lives when they have sat with legs crossed for too long, or fallen asleep with an arm crooked under their head.

It happens when sustained pressure is placed on a nerve.

The feeling quickly goes away once the pressure is relieved. Some individuals may experience

chronic paraesthesia. This is usually a symptom of severe underlying conditions.  Chronic paraesthesia is

often a symptom of an  underlying neurological disease or traumatic nerve damage.   Paraesthesia can be

caused by disorders affecting the central nervous system, such as stroke and transient ischemic attacks

(mini-strokes), multiple sclerosis, transverse myelitis, and encephalitis. A tumour or vascular lesion pressed

up against the brain or spinal cord can also cause paraesthesia. 

 Nerve entrapment syndromes, such as Carpal Tunnel Syndrome, can damage peripheral nerves and because 

paraesthesia accompanied by pain. When a person experiences paraesthesia, symptoms from a wide range

of possibilities may occur. There are number of potential causes as well; multiple sclerosis for

instance. The list below includes many of the potential causes of paraesthesia. 

- Migraines : 

Migraine headaches can cause throbbing in one particular area that can vary in intensity. Nausea and sensitivity to                   

light and sound are also common symptoms.

- Alcoholism : 

A chronic disease characterised by uncontrolled drinking and preoccupation with alcohol.

- Neuropathy

Weakness, numbness and pain from nerve damage, usually in the hands and feet.

- MalnutritionLack of sufficient nutrients in the body.

- Menopause :

A natural decline in reproductive hormones when a woman reaches her 40s or 50s.

- Dehydration

Dehydration can have causes that aren't due to underlying disease. Examples include heat, excessive activity, 

insufficient fluid consumption, excessive sweating or medication side effects.

- Fibromyalgia : 

Fibromyalgia is often accompanied by fatigue and altered sleep, memory and mood. Widespread muscle pain and   

 tenderness are the most common symptoms. Medication, talk therapy and stress reduction may help control 


- Herpeszoster :  

A reactivation of the chickenpox virus in the body, causing a painful rash. Also associated with 'Shingles'.

- Hypoglycaemia : 

Low blood sugar, the body's main source of energy. (Diabetes)

- Fabry Disease :

 Fabry disease is a rare genetic disease with a deficiency of an enzyme called alpha-galactosidase A.                                                   

 The disease affects many parts of the body including the skin, eyes, gastrointestinal system, kidney, heart, brain,                                 

 and nervous system. Symptoms of Fabry disease include: Episodes of pain and burning sensations.

- Nerve Irritation Atherosclerosis :

 Vagus-brain communication in atherosclerosis-related inflammation: a communication                                                                            

between the immune and central nervous systems.

- Hyperventilation

Hyperventilation syndrome (HVS) is a name given to a collection of physical and emotional symptoms, largely 

brought about by hyperventilation. This happens when we over-breathe. The main signs of this are when we   

breathe much more quickly and more shallowly than our bodies needs.

- Multiple Sclerosis : 

A disease in which the immune system eats away at the protective covering of nerves.

- Immune DeficiencyImmunodeficiency or immunocompromise is a state in which the immune system's ability to fight infectious     

disease and cancer is compromised or entirely absent. Most cases of immunodeficiency are acquired   

("secondary") due to extrinsic factors that affect the patient's immune system.

- Anticonvulsant Drugs : Anticonvulsants are a diverse group of pharmacological agents used in the treatment of epileptic               

seizures. Anticonvulsants are also increasingly being used in the treatment of bipolar disorder and                                                       

borderline personality disorder, since many seem to act as mood stabilizers, and for the treatment of                                                     

neuropathic pain.

- Lupus ErythematosusAn inflammatory disease caused when the immune system attacks its own tissues.

- Neurological Disorders

These disorders include epilepsy, Alzheimer disease and other dementias, cerebrovascular diseases   

including stroke, migraine and other headache disorders, multiple sclerosis, Parkinson's disease,                                                           

neuroinfections, brain tumours, traumatic disorders of the nervous system.


- Motor Neuron Diseases

Motor neurone disease is the progressive and fatal degeneration of certain nerve cells that control                                                         

muscles, symptoms, diagnosis, management.

- Lyme Disease Infection

A tick-borne illness caused by the bacterium Borrelia burgdorferi.

- Beta-Alanine Ingestion : 

Beta-alanine is a non-essential amino acid. ... Amino acids are the building blocks of proteins. Beta-                                                     

alanine is used for improving athletic performance and exercise capacity, building lean muscle mass,                                                     

and  improving physical functioning in the elderly.

- Autoimmune Disorders : 

A disease in which the body's immune system attacks healthy cells.


Lupus : An inflammatory disease caused when the immune system attacks its own tissues.

Coeliac Disease : An immune reaction to eating gluten, a protein found in wheat, barley and rye.

Sjögren's Syndrome : An immune system disorder characterised by dry eyes and dry mouth.

Multiple Sclerosis : A disease in which the immune system eats away at the protective covering of nerves.

Polymyalgia Rheumatica : An inflammatory disorder causing muscle pain and stiffness around the shoulders and hips.

Ankylosing Spondylitis : An inflammatory arthritis affecting the spine and large joints.

Type 1 Diabetes : A chronic condition in which the pancreas produces little or no insulin.

Alopecia Areata : Sudden hair loss that starts with one or more circular bald patches that may overlap.

Vasculitis : An inflammation of the blood vessels that causes changes in the blood vessel walls.

Temporal Ateritis : An inflammation of blood vessels, called arteries, in and around the scalp.

- Heavy Metal Poisoning : 

A toxic heavy metal is any relatively dense metal or metalloid that is noted for its potential toxicity,                                                         

especially in environmental contexts. The term has particular application to cadmium, mercury, lead and                                               

arsenic, all of which appear in the World Health Organization's list of 10 chemicals of major public                                                       


- Guillain-Barre Syndrome : 

A condition in which the immune system attacks the nerves. The condition may be triggered by an                                                         

acute bacterial or viral infection.


(The List above we have showed briefs on what they are, full explanations for each can be found within the

Book/Manual and how they cause Parathesia, and it's effects on CES.)

Symptoms of Paraesthesia

Interestingly, paraesthesia itself is something that can be considered a symptom of certain conditions. The

lack of one of the conditions mentioned in this article does not necessarily mean that a person is not experiencing

some level of paraesthesia. In addition, the paraesthesia a person experiences may be either chronic or transient.

When paraesthesia is caused by a particular condition, additional symptoms might become a part of the person's

experience, related to underlying causes. The symptoms of paraesthesia may include: Itching, Tingling, Foot drop,

Dysarthria, Numbness, Muscular atrophy, Ocular Dysmetria Restless leg syndrome, Crawling sensation on the skin,

"Falling asleep" of limbssuch as a hand, foot, arm, leg, etc.

Diagnosing Paraesthesia

Diagnostic evaluation of paraesthesia is based on the determination of the underlying condition that is causing

the person to experience paraesthesia sensations. A person's medical history, in combination with a physical

examination and laboratory testing, are essential for a diagnosis. A doctor might order other tests depending upon the

suspected cause of the paraesthesia the person is experiencing. Paraesthesia can be classified as either transient or

chronic. Transient paraesthesia might be a symptom of hyperventilation or a panic attack. Chronic paraesthesia can be

the result of nerve irritation, poor circulation, neuropathy, or a number of other conditions or causes. There is no form of

long-term physical effect from paraesthesia, although its underlying conditions can have a number of effects.

Treatment of Paraesthesia

Treatment of paraesthesia depends on an accurate diagnosis of the underlying cause. For people with limbs that

have fallen asleep, restoration of their circulation through exercising, stretching, or massaging the affected limb can

rapidly dissipate the tingling and sensations of numbness. If the paraesthesia is due to a chronic disease, such as

diabetes, or occurs as a complication of treatments like chemotherapy, the majority of treatments are aimed at relief of

the person's symptoms.  Anti-inflammatory medications such as ibuprofen or aspirin are recommended if the person's

symptoms are mild.  People with more difficult paraesthesia might be administered antidepressant medications such as

amitriptyline.  Antidepressant medications prescribed for paraesthesia are given at a much lower dosage than they are

for the relief of depression. The medications are believed to help because they alter the person's perception of pain. If

the paraesthesia a person is experiencing is even more severe, opium derivatives such as codeine might be rescribed.

As of the year 1998, trials are being performed in order to determine whether treatment with human nerve growth

factor will be effective in regenerating damaged nerves. There are also a number of alternative treatments available to

assist in relieving the symptoms of paraesthesia. Nutritional therapy can include B complex vitamin supplementation,

particularly vitamin B12.  Vitamin supplementation is something that should be pursued with caution; however, because

an overdose of Vitamin B6, for example, is one of the causes of Paraesthesia. People who experience paraesthesia

should avoid the consumption of alcohol.   Acupuncture and massage are also believed to provide a level of relief from

the symptoms of   paraesthesia. Self-Massage with aromatic oils is sometimes helpful as well. The application of

topical ointments that contain, capsaicin, the substance that makes hot peppers hot, might provide relief from

paraesthesia. It can also be helpful to wear clothes and shoes that are loose-fitting.

Quick Facts on Paraesthesia

Benzodiazepine withdrawal can cause paraesthesia as the drug removal leaves the GABA receptors stripped bare and

possibly malformed.  Joint conditions such as rheumatoid arthritis, psoriatic arthritis, and carpal tunnel syndrome are

common sourcesof paraesthesia.  Chronic paraesthesia indicates a problem with the functioning of neurons or poor

circulation.Stroke survivors and those with Traumatic Brain Injury (TBI)  may experience paraesthesia from damage to

thecentral nervous system.  Paraesthesia can also be a symptom of vitamin deficiency and malnutrition, as well

asmetabolic disorders like diabetes, hypothyroidism, and hypoparathyroidism. It can also be a symptom

of mercury poisoning. The herpes zoster disease (shingles) can attack nerves causing numbness instead of

pain commonly associatedwith shingles.  Medications offered can include the

immunosuppressant prednisone,intravenous gamma globulin (IVIG),anticonvulsants such as Gabapentin or Gabitril

and Antiviral medication, among others, according to theunderlying cause.

The plate above shows how relevant Cauda Equina Syndrome is connected to paraesthesia. 

We have shown you in this chapter what can cause CES. The next chapter Treatments for both ailments.

RED FLAGS  & How to Treat Them, Medication

Over-the-counter pain relievers can provide short-term relief from sciatica. Acetaminophen and nonsteroidal

anti- inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, and naproxen are options. Your doctor may

give you a steroid injection to further reduce the inflammation.

Relief: Injections into Nerve 

In severe cases, a doctor may recommend injecting steroids into the spine area to reduce inflammation. 

It delivers the medication directly to the area around the sciatic nerve.                                                                                                          



If your sciatica is due to a herniated disk, and it's still causing severe pain after four to six weeks,

surgery may be an option. The surgeon will remove a portion of the herniated disk to relieve the pressure on

the sciatic nerve. About 90% of patients get relief from this type of surgery. Other surgical procedures can

relieve sciatica caused by spinal stenosis.

 Last Form 0f Relief:       



 After  back surgery, you will generally need to avoid driving, lifting, or bending forward for about a month.

Your doctor may recommend physical therapy to help you strengthen the muscles in the back. Once recovery

is complete, there's an excellent chance you'll be able to get back to all your usual activities. There is evidence that

acupuncture, massage, yoga, and chiropractic adjustments can relieve typical lower back pain. But more research is

needed to determine whether these therapies are helpful for sciatica.

If you've had sciatica once, there's a chance it will return. But there are steps you can take to reduce the


1)  Exercise regularly.Maintain good posture.

2)  Bend at the knees to lift heavy objects.

3) These steps can help you avoid back injuries that may lead to sciatica orherniated discs, which could cause 

    Cauda Equina. Syndrome.

Cauda Equina Syndrome is a rare  and dangerous condition in which exposed nerve fibres(as shown below) located

at the bottom of the spinal cord become irritated. The irritation is caused by something with which the exposed

nerves come into contact.  The term Cauda Equina means “horse's tail” in Latin it is so named because of the

resemblance. Generally, the sensitive nerve tissue that comprises the spinal cord and nerve roots is encased in the

centre of the spinal column in an area known as the spinal canal. In this way, the highly responsive nervous tissue

is protected from structures that may put pressure on it (which will likely cause symptoms such as pain and/oraltered


Most of the time, Cauda Equina Syndrome is caused by a large, centralized herniated disc between the areas of

L4/5 and L5/S1. According to research reviewed by the British Medical Journal, only about 0.12% of all herniated

discs in the U.S. likely cause Cauda Equina.  Other, less common causes include trauma or injury to the spine that

leads to fractures and/or subluxations. Tumours or infections that compress the Cauda Equina may also cause

this syndrome. Bone spurs in the spinal canal are another possible cause. Tuberculosis,

Potts' paralysis and Iatrogenic causes (for example spinal manipulation while you're

under anaesthesia or postoperative complications e.g.: Haematomas, ) are also implicated, as are things may

that occupy spinal spaces, such as cysts. You may be predisposed to Cauda Equina Syndrome if you have Spinal

Stenosis (either congenital or acquired). If acquired stenosis underlies your cauda equina syndrome, most likely the

Stenosis comes from disc degeneration and degeneration of your Facet Joints. You may also have a thickened

ligament flavum and a narrowing of your spinal canal.

Cauda Equina Syndrome Symptoms

Cauda Equina Syndrome is roughly categorized into 3 basic types, according to the defining symptom of 

urinary retention. Complete CES is accompanied by urinary retention while incomplete is not. With complete

CES, urinary retention has already been diagnosed. With incomplete CES, you may experience reduced

urinary sensation, have a small stream, or similar symptoms, but you're still able to urinate.  Urinary

retention can be serious and that's why it's very important to get checked if you notice any changes in this

functionality. Other symptoms of CES include sexual dysfunction, dysfunction of the bowel and/or numbness or other

sensory changes around your anus. (Numbness around the anus is called "saddle anaesthesia.") Of course, back pain

is a symptom, as are sensory or motor changes in your lower limbs (including weakness and/or loss of reflexes and

more.) Back pain is a symptom, as are sensory or motor changes in your lower limbs (including weakness and/or

loss of reflexes and more.) Cauda Equina Syndrome symptoms may present themselves in one of

three general patterns, which are labelled as:

“types.” They are: 

Type 1: Symptoms are acute and come on very suddenly and intensely. Symptoms of CES caused by a

             herniated disc present in this way. 

Type 2: As the final destination after a long journey of chronic back pain, with or without sciatica. 

Type 3: Insidiously, where you've slowly been experiencing more and more numbness, as well as

             urinary symptoms.

 Diagnosing Cauda Equina Syndrome

Cauda Equina Syndrome is a result of an interruption or dysfunction of the nerves associated with the +

lumbar and sacral vertebrae. However, such disruption is only diagnosed as cauda equina when your bladder,

bowel and/or sexual function is impaired. This includes the symptom of saddle numbness or

saddle anaesthesia, discussed briefly earlier, which is loss of feeling around the anus.

CES is diagnosed with MRI, myelogram, specialized nerve testing such as nerve conduction velocity

tests and/or electromyography, CT scans. If your doctor suspects you have cauda equina, you'll be subjected

to a physical exam that uses palpation (touch) to determine the degree of feeling and response around

your anus and rectum. ​


Most of the time, CES is due to a herniated disc; therefore, the treatment of choice will likely be spinal

decompression surgery, probably a discectomy.  Once your CES diagnosis is confirmed by your doctor, and if your MRI

shows that the cause of the pressure on the CES is reversible, at that point, surgery may make the most sense as an

immediate treatment option.  With that said, sometimes emergency surgery is required to enable you to

avoid permanent dysfunction of your lower extremity (or extremities) as well as your bladder, bowel or sexual

functioning, the time gap for these functions to start to fail is uniquely small, 12 - 24 hours in some patients. Longer

than 36 Hours and the patient is in real danger of losing all functionality.  The effects of untreated Cauda Equina

Syndrome can be devastating; the same is true for Cauda Equina Syndrome that is treated too late, time is the biggest

healer in the treatment of CES. Do not delay in speaking with your doctor about your treatment options.  If something

other than a herniated disc is creating the pressure on your Cauda Equina, you'll likely need to work with a specialist or

team of specialists to address that problem, as well.

When in Doubt, Get It Checked Out!

The controversies around diagnosis and treatment of CES can easily complicate

decision making. However, this condition is potentially life-threatening, especially so if you do not heed your

symptoms. If you notice symptoms, speak with your doctor as soon as you can. When it comes to Cauda

Equina Syndrome, it's only natural to feel embarrassed about discussing what you notice, or apprehensive

about getting checked.  But remember, doing so in a timely way may save your life or at the very least, your

quality of life.  The purpose of the survey and study we undertook was to identify and descriptively compare

the RED FLAGS endorsed in guidelines for the detection of serious pathology in patients presenting with low

back pain to primary care.



 We searched databases, the World Wide Web and contacted experts aiming to find the

multidisciplinary clinical guideline in low back pain in primary care, and selected the most recent one per country. We

extracted data on the number and type of red flags for identifying patients with a higher likelihood of serious pathology.

Furthermore, we extracted data on whether or not accuracy data (sensitivity/specificity, predictive values, etc.)

were presented to support the endorsement of specific RED FLAGS.

We found discrete guidelines all published between 2000 and 2015. One guideline could not be

retrieved and after selecting one guideline per country we included 16 guidelines in our analysis from 15 different

countries and one for Europe as a whole. All guidelines focused on the management of patients with low back pain

in primary care or multidisciplinary care setting. Five guidelines presented red flags in general, i.e., not related to any

specific disease. Overall, we found  to 6 discrete RED FLAGS related to the four main categories of serious

pathology the main being Cauda Equina Syndrome.

The majority of guidelines presented for SEVEN RED FLAGS for Cauda Equina Syndrome.  Quite often

pain at night or at rest was considered as a RED FLAG for various underlying pathologies. We based our choice

of RED FLAGS on consensus or previous guidelines; five did not provide any reference to support the choice

of RED FLAGS, three guidelines presented a reference in general, and data on diagnostic accuracy was

rarely provided.   A wide variety of red flags was presented in questions for low back pain, with a lack of consensus

between guidelines for which RED FLAGS to endorse. Evidence for the accuracy of the recommended RED

FLAGS was lacking. Low back pain remains a common condition among primary care patients with an

estimated lifetime prevalence of 13.8 % for chronic pain and 80 % for an episode of pain on a scale of

1 - 5European guidelines for the management of low back pain in primary care define low back pain as

‘pain and discomfort’’ localized below the costal margin and above the inferior gluteal folds, with or without

leg pain.

Non-specific low back pain is commonly defined as low back pain without any known pathology.  Although nonspecific

low back pain accounts for about 85–90% of back pain, which could be Sciatica, herniated disc, fracture of vertebrae or

tearing of tendons and muscles supporting the spine or a Sacral injury. remaining patients may have neurologic

impairments (e.g., spinal stenosis, radiculopathy) or serious underlying diseases (e.g., fractures), of which the latter

necessitates timely and accurate diagnosis. Serious pathology in patients presenting with low back pain includes

Cauda Equina Syndrome (CES), infection or  aortic aneurysms. Spinal malignancy and vertebral fracture are the most

frequent serious pathologies of the spine. However, the absolute magnitude of occurrence may be regarded as rare.

Among patients with low back pain presenting in primary care less than 1 % will have spinal malignancy (primary

vertebral tumour or vertebral metastasis) and about 4 % will have a spinal fracture. CES or spinal infections are even

rarer, with an estimated prevalence of 0.04% and 0.01 %, respectively, among patients with low back pain but the

outcome of the survey was inconclusive as to exactly what the cause was. This being CES or an infection.  It was hard

to dissimilate between the data so the assumptions were taken into account that the resultant low back pain was the

prelude to CES and further evidence supported this assumption.

The spine is the most common bony site for musculoskeletal tumours. The majority of spinal malignancies are

the result of metastases of other tumours in the body, mainly from breast, lung or prostate cancer. Vertebral

compression fractures occur in almost 25 % of all postmenopausal women and the prevalence of compression

fractures linearly increases with advancing age, up to 40 % in women 80 years of age. Clinicians are advised

by guidelines to evaluate serious underlying pathology by checking for Red Flags (or alarm signals) during the

history taking and physical examination. The presence of red flags may indicate underlying serious

pathology in patients with low back pain.

Current guidelines often present a list of red flags, which are considered to be associated with an increased

risk of the presence of underlying serious pathology in the spine, often without consideration given to the

diagnostic accuracy of the RED FLAG (test).

Here we have to note the main seven RED FLAGS that we were looking for from the guidelines but have

included (Twelve) 12 in total.:

1. Bladder Incontinence can be permanent with a Super Pubic Catheter with BOTOX injections six or twelve monthly

    for spasms.

2. Bowel and Faecal Incontinence.   

3. Permanent or partial Sexual Dysfunction.

4. Radiated pain down one or both legs.

5. Unable to Stand, Sit, Or Lie flat for long periods, require a bed that gives a "0" Gravity effect taking the 

    pressure of the spine.

6. Walking without an aid, mobile walker or walking stick/s is impossible and some CES sufferers require         


7. Major depression, Anxiety, Stress (bordering on PTSD - Post Traumatic Stress Disorder) and Panic Attacks, even 

    nightmares due to some of the medications and the shock of the diagnosis

The above 7 (seven) are the main characteristics Doctors should be looking for. Any 3 (three) of them could

lead to a diagnosis of CES. The next 5 (five) are not to be discarded either and could be linked with any of the

above to put doubt in the mind of the Doctor,  BUT, there must be two of the above and linked with one

of the following five the question must be asked,  Is It CES or Not ?

8. If Nerves in the upper part L1 or TH 12, cause problems in the Lower Diaghram not allowing the

    patient to take deepbreathes, would eventually cause Chronic Obstructive Pulmonary Disease


9.   Reduced appetite

10. Rapid fatigue and general malaise.

11. Fever.

12. Paraparesis, and progressive symptoms.

While most guidelines recommend screening for RED FLAGS, there is variation in which red flags are endorsed,

and there exists heterogeneity in precise definitions of the RED FLAGS (e.g. ‘trauma’, ‘severe trauma’, ‘major


An overview of recommended RED FLAGS in the guidelines is lacking. So, therefore, CES can be broken down

into three categories. 

Please Note: there is actually four main categories which will be shown further on.

CES – R: Restricted which may involve any 3 of the above,

CES – T: Trauma, this involves at least 4+ of the above and

CES – MT: Involves all Twelve of the above. 

The purpose of our survey and the results was to identify and compare the RED FLAG recommendations in

current guidelines for the detection of medically serious pathology in patients presenting with low back pain.

Overview of RED FLAG screening in low back pain. We searched for clinical guidelines in primary health care

concerning adults with low back pain date of the last search was from January to April 2018. Our starting point was a

previously published review article including many guidelines we settled on 10 National and International guidelines.

For diagnosis and treatment of low back pain. First, we checked for updates of these 10 guidelines.

Additionally, we searched for other clinical practice guidelines using electronic databases: Medline, Pedro,

MEDeD, Healthline and Rare Disorders (NORD), using the keywords: low back pain, practice guidelines,

clinical guidelines, National Guideline For Low Back Pain, and Government Ministries of Health for registered

Cauda Equina Syndrome patients or Low Back Pain and Sciatica and The National Institute for Health and

Clinical Excellence (UK) as well as The John Hopkins Research Centre along with the Mayo Clinic Research

Department on Lower Back Disorders, Universities, and as mentioned earlier London School of Spinal

Surgery.  To use a Gene Rodenberry term the creator of "Star Trek" "We basically went where no-man has gone

before" looking for data.

 Furthermore, we performed searches via Google, performed snowballing and citation tracking on

publications that consulting experts with peer reviews in the fields of Spinal Surgery and Neurology fields.

The search was aimed at finding all the clinical guidelines that exist. No language or date restriction was

applied. Health care practitioners and patients were asked to make decisions about appropriate health care for

low back pain under the auspices of a medical specialty associated with further problems, and the survey

results further on in this area are from relevant professional societies public or private organizations.

When one country had more than one guideline, we selected the most recent multidisciplinary guideline.

Data Extraction

 We extracted data on the number and types of red flags for serious pathology for each guideline using a 

standardized form for both individuals and medical associations. For each red flag, we scored if the

RED FLAGS was supported by the literature presenting its accuracy on sensitivity, predictive values, etc. if it was

supported by the consensus of the guidelines set out in the survey cover introduction. No information was

given to support the endorsement of any red flags. We only required a summary.

First, of the original 10 guidelines of previously published review articles, we found and used we excluded the

European guideline for chronic low back pain. The reason for this was given that RED FLAGS were presented in

the European guideline for acute only low back pain which defeated what we were really trying to discover.

 Eight countries updated their guidelines they being Austria, Canada, Finland, Germany, Netherlands, Norway,

Spain, United States, and Australia. New Zealand and Asia failed to reply, but we had some information from

New Zealand already and included it within the data.

Of the reply countries three, we found more than one updated guideline Austria, Netherlands, and the United

States. Austria including an update of a multidisciplinary guideline from 2017 and one specifically for

radiologists of which we selected the multidisciplinary one. The updated guidelines from The Netherlands

included a multidisciplinary guideline and one specifically for physiotherapists and Osteopaths of which we selected the

multidisciplinary one.  The United States had two multidisciplinary guidelines and one specifically for

physiotherapists, of which we selected for this overview of the latest multidisciplinary guideline linked to a

website. The guidelines of Finland and Norway were not available in English, so colleagues were contacted to

extract the relevant data and translate for us. Their data was for Physios, Osteopaths and Chiropractors. Our next step

in carrying out this survey was to perform a broad search aiming to identify additional guidelines.  In total, we identified

21 guidelines, of which eleven were excluded. As we selected one guideline per country. We found three new

guidelines Philippines, Malaysia, and Mexico, of which one guideline Mexico could not be retrieved Finally, 10 discrete

guidelines were included in this review.

Description of the guidelines to suit our survey

The guidelines were published between 2016 (France) and 2018 (Finland), with the publication date of one

guideline unknown (Malaysia) but appear it may have been 2017. The target population was mostly adults (25

to 70 years of age) with low back pain. Seven RED FLAGS used the term specific low back pain, three also

included people with radiculopathy, four guidelines specifically focused on patients with acute low back pain

defined as a duration less than 3 months, and one guideline included patients with acute and/or recurrent low

back pain New Zealand finally submitted information on this matter.

                                Click On Image To Go To Section 2 Of RED FLAGS





Make an Enquiry


Cauda Equina Syndrome Sufferers Global Support Group