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)

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.

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.