Common Middle Back Pain Red Flags

Back pain is very common—four out of five people experience back pain at some point in their lives. Most of the time back pain isn't serious, but sometimes it's a signal that something concerning could be going on with your health. 

Some of the most serious conditions that can lead to back pain include spinal infection, cancer, and a problem known as cauda equina syndrome, in which compressed nerve roots cut off sensation and movement.

This article lays out the most common red flags healthcare providers generally check for during a medical evaluation for back pain.

Age

If you are younger than 18 or older than 50, acute back pain may be cause for concern. Back pain in people younger than 18 without a history of trauma may indicate a stress fracture in a vertebra. Gymnasts, weight lifters, and other athletes who experience repeated stress to the lower back are susceptible to this kind of injury.

If you are experiencing severe pain, especially at night, if you recently lost weight without trying, or if your pain gets worse when you lie on your back, these red flags may be a sign of a spinal tumor or cancer.

If you are older than 50, new back pain may signal a number of potential conditions, including a tumor or spinal infection. New back pain may also indicate something as common as kidney stones or as serious as an abdominal aortic aneurysm, a life-threatening weakness in the major vessel that supplies blood to your legs.

If your healthcare provider expresses concern about cancer at your appointment, they may refer you to another specialist for further testing. 

Fever, Chills, or Recent Illness or Surgery

A fever may indicate an infection, such as meningitis, infection in the​ epidural space around your spinal cord, or surgery-related infection.

Common symptoms of spinal infection include, but are not limited to, fever, chills, stiff neck, and/or unexplained weight loss.

Fever, chills, or recent illness with low back pain may be a sign of a spinal epidural abscess, an infection between the outer covering of the spinal cord or nerve roots and the bones surrounding it.

Spinal epidural abscesses can occur in people who have boils, infections in the bloodstream or bones of the spine, and those who have recently had back surgery. People who use intravenous drugs are also at increased risk for spinal epidural abscess.

A recent lumbar puncture during surgery or an epidural injection to help with back pain, for example, can also increase the risk of an infection or epidural hematoma (pooling of blood on the outer covering of the brain or spinal cord and nerve roots).

With a spinal infection, it is imperative to get an accurate diagnosis as quickly as possible.

Treatment focuses on eliminating the infection and relieving pain. Improved nutrition can boost your immune system through overall diet changes. Or it can add specific nutrients, like vitamin D and calcium to prevent bone loss due to osteoporosis, which can lead to complications like infection after a spinal injury.

These strategies may be part of a treatment plan to maintain spinal stability, and to preserve and restore the function of your nervous system.

Trauma

Major trauma, such as a bad car accident, significant fall, or sports injury, may result in a fracture of the spine. A vertebral fracture may additionally injure surrounding nerves or the spinal cord itself.

However, even minor trauma can be cause for concern, particularly if you are older than 50 or have (or are at risk for) osteopenia, osteoporosis, cancer, or another condition that weakens the bones. Reaching, twisting, or falling from standing height are examples of minor trauma that may damage the spine. 

If you are using anticoagulant medication, trauma can also result in an epidural hematoma. If this is the case, you may have back pain, weakness, or tingling in your arms or legs.

History of Cancer

If you currently have cancer or had it in the past, back pain may indicate a recurrence or metastasis, where the cancer has spread to other parts of the body.

Back pain that worsens over several months, unexplained weight loss, and pain at night or at rest may also indicate cancer.

Some types of cancers are especially likely to put pressure on the spine. Spinal cord compression is a common complication of prostate, breast, and lung cancers. Patients with metastatic bone cancer may also develop epidural spinal compression.

Night Pain or Pain at Rest

Experiencing back pain at night or at rest can be (but isn't necessarily) a sign of a serious condition such as an infection or cancer.

This is particularly true if your night or resting back pain occurs alongside another symptom. For example, pain at night and recent weight loss, especially in adolescents, are red flags for cancer and warrant a visit to your healthcare provider.

Incontinence and Saddle Anesthesia

Soiling yourself without realizing it, numbness in your groin or inner thigh, or both may be signs of nerve problems, including cauda equina syndrome.

In this syndrome, compressed nerve roots in the lumbar spine cut off sensation and movement in the buttocks and inner thighs (known as saddle anesthesia). Loss of feeling and paralysis can become permanent without quick treatment.

When accompanied by new and severe back pain, saddle anesthesia is often associated with cauda equina syndrome.

Other common symptoms of cauda equina include being unable to empty your bladder completely, increased frequency of urination, and overflow incontinence (you feel the urge to urinate but can release only a small amount).

Patients with this condition also frequently report sexual dysfunction and leg weakness or sciatica, especially if these symptoms are severe or keep getting worse.

Weak, Numb, or Painful Leg Muscles

Your healthcare provider may test the strength of both your legs, particularly if your back pain came on suddenly and you are experiencing nerve pain. Weakness in your legs may indicate spinal cord or nerve root compression.

If you experience back pain often and the strength of your lower limbs has become weaker, it may be a sign of neurological damage.

Summary

Back pain is incredibly common and in many cases doesn't signal a concerning medical problem, but there are some signs indicating that it may be caused by something serious. Back pain that becomes worse at night, for example, may be a sign of cancer. A fever accompanying new back pain could signal an infection. Age, numbness, and incontinence are also red flags to consider when assessing what's causing back pain.