Emergency physio insights: Spotting red flags in spinal cases

Many of us know the feeling: lying awake at night, replaying a case in your head, and worrying you might have missed a red flag.

Luckily, while spinal issues are one of the most common musculoskeletal presentations, red flags for spinal pathology present very rarely in most settings. However, in the Emergency Department (ED) the stakes are higher.

Unlike primary care, ED physios are often the first point of specialist musculoskeletal contact for patients in crisis, so they have to be exceptional at screening for red flags. This blog takes a look at how expert ED physio David O’Brian approaches the screening process for acute spinal presentations.

For an in-depth understanding of the management of acute musculoskeletal presentations in an emergency setting, watch David’s full Masterclass HERE.

Red flags

The first priority in the ED setting is identifying or ruling out serious pathology. While the vast majority of spinal pain presentations are benign, ED physios must be fluent in spotting red flags and knowing when further investigation or escalation is needed.

The most frequently encountered serious spinal pathology in ED is fracture. These can be traumatic or osteoporotic in nature, with thoracic fractures particularly common due to osteoporosis. Cauda Equina Syndrome (CES) is also a presentation physiotherapists, regardless of setting, need to be able to identify.

Fractures

Key fracture risk factors include: previous osteoporotic fracture, age over 65, rheumatoid arthritis, diabetes, long-term corticosteroid use, smoking, excessive alcohol consumption, and certain gastrointestinal disorders.

Clinically, fractures present as sudden severe localised pain, often disproportionate to activity. Imaging is vital, but X-ray alone has only around 50% sensitivity in osteoporotic fractures, so CT is often ordered.

Management involves strong analgesia, mobility assessment, and referral to the specialist spinal team for guidance on stabilisation and follow-up.

Cauda Equina Syndrome

CES is rare but time-critical. Most cases are caused by lumbar disc prolapse, but tumours, stenosis, or trauma can also be culprits. It is more common in females aged 30–49, and importantly approximately 70% of patients have a background of chronic low back pain (so don’t miss these!). There are three main clinical patterns to look out for:

1. Rapid onset without previous back issues.
2. Acute bladder dysfunction in a patient with a history of low back pain (with or without sciatica).
3. Chronic low back pain and sciatica with worsening pain and new bladder/bowel dysfunction.

Timely recognition and escalation for these patients is integral, as delayed management can result in permanent neurological deficits. See David describe how to identify red flags for CES in the below snippet from his Masterclass:

Radiculopathy needing urgent referral?

As physios, we often find ourselves in the position of having ruled out serious pathology, identified radiculopathy as the source of symptoms, and then needing to decide whether it warrants urgent specialist referral.

Not all neurological involvement demands immediate referral, and we are often playing the balancing act between ensuring the patient receives the appropriate, timely management, without encouraging catastrophisation of their condition.

We need to assess myotomes, dermatomes and reflexes to localise the affected nerve root and understand the severity of the patient’s radiculopathy. David points out the key concern is motor loss; if weakness is mild, non-progressive, and confined to a single myotome, conservative management is usually safe. However, if there is profound motor weakness or deterioration despite conservative care, urgent specialist referral is warranted.

This balance between recognising what can be safely managed and what requires escalation (and doing so efficiently as possible!) is at the heart of ED physiotherapy practice. In the below video from his Masterclass, David demonstrates how he conducts his lower-limb motor and sensory exam in the ED setting:

Wrapping up

Screening acute spinal symptoms requires a sharp eye for red flags, but also the ability to contextualise findings within each patient’s presentation.

Fractures remain the most common serious pathology, but physios must stay alert for a range of other pathologies, from CES to malignancy and infection. Equally, in the case of radiculopathy, not all neurological symptoms require immediate action, careful assessment of motor involvement guides whether urgent referral is required.

Ultimately, we can learn a lot from the way ED physios screen and manage acute musculoskeletal conditions. By combining a systematic red flag screen with sound clinical reasoning, we can ensure patients receive timely, safe, and effective care in every clinical setting.

If you want to know exactly how expert ED physio David O’Brian manages acute patients, watch his full Masterclass HERE.