Tick all flags present — referral guidance updates automatically
No red flags ticked. Screen all flags below before proceeding with assessment.
Saddle anaesthesia (numbness in perineum / inner thighs)
Loss of sensation in the saddle area — S3–S5 involvement
Bladder dysfunction (retention or incontinence)
New onset urinary retention or loss of bladder control
Bowel dysfunction (incontinence or retention)
New onset faecal incontinence or inability to defecate
Bilateral leg weakness or progressive neurological deficit
Rapidly worsening bilateral lower limb weakness
History of cancer (any type)
Previous or current malignancy — spinal metastasis must be excluded
Unexplained weight loss (>10% body weight in 3 months)
Unintentional significant weight loss without dietary change
Night pain that wakes from sleep (non-positional)
Constant, unrelenting pain not relieved by rest or position change
Age > 50 with new onset back pain and no mechanism
New spinal pain in older adults without trauma or clear cause
Fever > 38°C with spinal pain
Systemic fever accompanying musculoskeletal pain — discitis/osteomyelitis
Recent infection (UTI, skin, respiratory) + spinal pain
Haematogenous spread to spine is possible
IV drug use + spinal pain
High risk of septic discitis or epidural abscess
Morning stiffness > 1 hour, age < 40, improves with exercise
Possible inflammatory arthropathy (ankylosing spondylitis, PsA)
Pulsatile abdominal mass or severe tearing back pain
Possible abdominal aortic aneurysm — life-threatening
Sudden onset severe headache ('thunderclap')
Subarachnoid haemorrhage until proven otherwise
Neck pain + dizziness + diplopia + dysarthria + dysphagia
Vertebrobasilar insufficiency or vertebral artery dissection
Significant trauma (fall from height, RTA, direct blow)
Spinal fracture must be excluded before treatment
Osteoporosis + minimal trauma + acute spinal pain
Vertebral compression fracture risk in osteoporotic patients
Steroid use (long-term) + spinal pain
Corticosteroid-induced osteoporosis increases fracture risk
Progressive neurological deficit (worsening weakness / numbness)
Deteriorating neurology despite conservative treatment
Upper motor neurone signs (clonus, hyperreflexia, Babinski +ve)
Cervical myelopathy or central cord lesion
Acute onset foot drop
L4/L5 nerve root compression or peroneal nerve palsy
Active suicidal ideation or self-harm
Patient safety concern — immediate mental health support required
Physio Pearls — Red Flag Screener · For clinical decision support only · Always apply clinical judgement