Ruling Out Serious Causes
Low back pain is one of the most common reasons patients seek medical attention, affecting up to 80% of people at some point in their lives. In most cases, the pain is benign and self-limited. However, in a small but critical subset of patients, low back pain can signal something much more serious—like infection, malignancy, fracture, or inflammatory disease. Identifying these red flags early is essential for timely diagnosis and effective treatment.
Let’s break down the major red flag categories and highlight a real-life case to illustrate the importance of clinical vigilance.
Red Flag Categories in Low Back Pain
1. Infection (0.01–0.7%)
Signs to watch for:
• Fever or recent infection
• Immunocompromised state
• IV drug use
• Severe, progressive pain not relieved by rest
• Night sweats, weight loss
2. Malignancy (0.7–1%)
Red flags:
• History of cancer
• Unexplained weight loss
• Age over 50
• Failure to improve with conservative therapy
• Pain at night or at rest
3. Fracture (4%)
Clues include:
• History of trauma (but not always required)
• Prolonged corticosteroid use
• Osteoporosis
• Age over 70
• Sudden onset pain with limited mobility
4. Inflammatory (0.3–5%)
Look for:
• Age <40, insidious onset
• Morning stiffness >30 minutes
• Improvement with activity, not rest
• Systemic symptoms
• Family history of autoimmune disease
A Case to Remember: The Hidden Sacral Fracture
One of the most satisfying cases I’ve treated was an elderly woman—a mother and grandmother—who presented with severe lower back and pelvic pain. She had no history of trauma, falls, or recent weight loss. Yet her pain was so debilitating she required moderate to maximum assistance for transfers and ambulation. She was evaluated at multiple healthcare settings without relief.
Advanced imaging revealed the often-overlooked culprit: a sacral insufficiency fracture—a subtype of osteoporotic fracture that can occur spontaneously in older adults with fragile bones. It’s frequently missed or misdiagnosed due to vague symptoms and lack of an inciting event.
Fortunately, I performed a sacroplasty—a minimally invasive, image-guided procedure that stabilizes the sacrum using bone cement. The results were dramatic. Her pain diminished significantly, and she quickly returned to functional independence with activities of daily living (ADLs).
Takeaway: Don’t Miss the Red Flags
While most cases of low back pain will improve with conservative care, red flags are a critical part of the initial evaluation—especially in older adults, those with unexplained disability, or symptoms that don’t follow the typical pattern.
As clinicians, it’s our job to not just treat the symptoms, but to find the “why.” And sometimes, as in this case, the answer is hiding in plain sight.
If you or a loved one is struggling with severe or persistent back pain, don’t ignore it. Schedule a consultation with Dr. Amir Mahajer to determine the cause and explore targeted treatment options—including minimally invasive procedures like sacroplasty.
