• While this term is overused and must be taken in context of the full assessment, the presence of one of these features may be the only indication of a significant underlying diagnosis.

History

• Age younger than 20, or older than 55
• Trauma
• Known malignancy
• Nocturnal pain
• Thoracic pain
• Systemic symptoms (fever, weight loss)
• Significant pain on mobilizing that disappears at rest (may represent instability pain)
• Perineal (‘saddle’) numbness
• Bladder or bowel symptoms
• Severe or progressive limb neurological deficit

Examination

• Spinal deformity (e.g. kyphosis, ‘step’ in the posterior spine)
• Bony spinal tenderness, particularly if thoracic
• Significant weakness
• Sensory level (i.e. a loss of sensation in all dermatomes below a certain level)
• Upper motor neuron dysfunction (e.g. spasticity, brisk reflexes, extensor plantars)
• Sacral dysfunction (e.g. absent anal tone, urinary retention, perineal/perianal numbness)