Approfondimenti del Fisioterapista d’Emergenza: Riconoscere le Red Flags nei Casi Spinali

Many of us know that feeling well: lying awake at night, thinking back to a case and fearing we may have missed a red flag.

Fortunately, although spinal problems are among the most common musculoskeletal presentations, red flags for serious spinal conditions are actually very rare in most settings. However, in the emergency department (ER), the stakes are higher.

Unlike primary care, ED physical therapists are often the first point of contact for acutely ill patients with a musculoskeletal specialist, so they must be exceptional at screening for red flags. This blog explores how experienced ED physical therapist 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 is to identify or rule out serious pathologies. Although the vast majority of spinal pain presentations are benign, physical therapists in the ED must be skilled at recognizing red flags and knowing when to request further investigation or promptly report to a specialist.

The most common serious spinal pathology encountered in the emergency department is fracture. These can be traumatic or osteoporotic, with thoracic fractures being particularly common due to osteoporosis. Cauda equina syndrome (CE) is another presentation that physical therapists, in any setting, must be able to identify.

Fractures

Major risk factors for fracture include: previous osteoporotic fracture, age over 65, rheumatoid arthritis, diabetes, prolonged use of corticosteroids, smoking, excessive alcohol consumption, and certain gastrointestinal diseases.

Clinically, fractures present with sharp, severe, localized pain, often disproportionate to activity. Imaging is essential, but radiography alone has a sensitivity of approximately 50% in osteoporotic fractures, so CT is often required.

Management includes strong analgesia, mobility assessment, and referral to the spinal specialist team for stabilization guidance and follow-up.

Cauda Equina Syndrome

CE is rare but management is time-dependent. Most cases are caused by a lumbar disc prolapse, but tumors, stenosis, or trauma can also be causes. It is more common in women between the ages of 30 and 49, and approximately 70% of patients have a history of chronic low back pain (so be careful not to underestimate them!).
There are three main clinical patterns to keep in mind:

1. Rapid onset with no previous lumbar problems.
2. Acute urinary 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 urinary or bowel dysfunction.

Early recognition and escalation are crucial, as delayed management can lead to permanent neurological deficits. In his Masterclass video (below), David demonstrates how to identify the red flags for CE.

Radiculopathy requiring urgent referral?

As physiotherapists, we often find ourselves in situations where we have ruled out serious pathologies, identified radiculopathy as the source of the symptoms, and must decide whether to request an urgent specialist referral.

Not all neurological involvement requires immediate referral, and we often have to balance ensuring the patient receives appropriate and timely management while avoiding fueling catastrophizing.

We must evaluate myotomes, dermatomes, and reflexes to localize the affected nerve root and determine the severity of the radiculopathy. David emphasizes that the primary concern is motor loss: if the weakness is mild, non-progressive, and confined to a single myotome, conservative management is generally safe. However, if there is marked weakness or deterioration despite conservative treatment, urgent referral is necessary.

This balance between recognizing what can be safely managed and what requires referral (and doing so as efficiently as possible!) is at the heart of physiotherapy practice in the ED. In the video below, taken from the Masterclass, David demonstrates how he conducts his motor and sensory examination of the lower extremities in the ED.

Conclusions

Screening for acute spinal symptoms requires a keen eye for red flags, but also the ability to contextualize the signs within the patient’s presentation.

Fractures remain the most common serious pathology, but physical therapists must remain vigilant for a range of conditions, from CE to tumor and infection. Likewise, in cases of radiculopathy, not all neurological symptoms require immediate intervention: a thorough assessment of motor function determines the need for urgent referral.

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

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